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j^,,         DISEASES 


OF   THE 


NEKTOIIS   SYSTEM. 


BY 

JEROME  K.  BAUDUY,  M.D.,  LL.D., 

PROFESSOll   OF   DISEASES   OF  THE  MIND   AND    NERVOUS   SYSTEM   AND    OP   MEDICAL   JURISPRUDENCE, 
MISSOURI    MEDICAI,    COLLUGE,   ST.  LOUIS  ;    LATE    PHYSICIAN    IN    CHIEF    TO    ST.    VINCENT'S 
INSTITUTION    FOR    THE    INSANE;    CORRESPONDING    MEMBER    OF   THE    NEW   YORK 
SOCIETY    OF    NEUROLOGY     AND    ELECTROLOGY  ;     FORMRRLY    CONSULTING 
PHYSICIAN   OF   THE  ST.  LOUIS   COUNTY    LUNATIC   ASYLUM  ;   MEM- 
BER  OF   THE   NEW    YORK   MEDICO-LEGAL   SOCIETY,    ETC, 


SECOND    EDITION. 


PHILADELPHIA: 

J.    B.    LIPPINCOTT    COMPANY. 

18  9  2. 


Copyright,  1892, 

BY 

J.  B.  LipPiNCOTT  Company. 


Printed  by  J.  B.Lippincott  Company,  Philadelphia. 


■J 

2? 

JCf 


THIS  WOEK 
IS  RESPECTFULLY  DEDICATED 

TO 

J.   M.   DA  COSTA,   M.D.,  LL.D., 

EMERITUS  PEOFESSOR  OF  PRACTICE  OF  MEDICINE  AND  OF  CLINICAL  MEDICINE 
AT   JEFFERSON    MEDICAL    COLLEGE,  PHILADELPHIA, 

BY    HIS 

FRIEND   AND    FORMER   PUPIL, 
THE  AUTHOR. 


CONTENTS. 


LECTTJEE    I. 

PAGE 
THE   CEREBRAL   CIRCULATION.  11 

LECTUEE    II. 

GENERAL  HYPEREMIA  OF  THE  BRAIN. 

Definition — Active  Hyperoemia — Causes  :  Emotions,  Fevers,  Diseases,  Slight 
Resistance  of  Capillaries,  Pressure,  Malaria,  Cold,  Atrophy  of  the  Brain,  Paral- 
ysis of  Vaso-Motor  Nerves,  Alcohol,  etc. — Irritation  of  Vaso-Motor  Nerves : 
Poisons,  Alcohol,  Excessive  Mental  Work — Passive  Hypersemia — Causes: 
Strangulation,  Pressure,  Expiratory  Efforts,  Impediments  to  the  Heart's  Action, 
Compensation,  Altered  Structure  or  Function  of  the  Lung — Post-Mortem 
Changes — Active  Congestion — Anaemia  produced  by  Collateral  CEdema — Forms 
of  Hypersemia — Symptoms  of  Mild  Hypersemia — Severe  Form — Delirium — 
Insanity — Hallucination — Illusions — Apoplectic  Form — Common  Symptoms — 
Diagnosis — Prognosis — Treatment — Partial  Form  of  Hypersemia 29 

LECTUEE    III. 

PARTIAL   ANEMIA    OF    THE    BRAIN. 

Definition — Closure  of  Vessels — Collateral  (Edema — Pressure  upon  Capillaries — 
Thrombosis — Embolism— Rheumatism — Thrombosis  as  a  Cause  of  Embolism — 
Aneurism  as  a  Cause — Artificial  Production  of  Embolism — Effects  of  Closure — 
Collateral  Circulation — Ligation  of  Carotid  in  Man  ;  in  Animals — Embolism  in 
Left  Side — Why  the  Right  Side  is  generally  paralyzed — Fissure  of  Sylvius — 
Brain  not  Uangrenous — Cause  of  Absence  of  Gangrene — Cause  of  Presence  of 
Gangrene — Collateral  Hypersemia — Secondary  Antemia — Compression  of  Capil- 
laries— Change  of  Color — Hemorrhagic  Infarction — Size  of  Softened  Parts — 
Anatomical  Condition  in  Ansemia — Pathological  Effects  of  Pressure — Symptoms 
of  Softening  of  the  Brain — Degrees  of  Functional  Derangement — Symptoms  of 
Excitation  and  of  Depression  :  Amnesia,  Agraphia,  Aphasia,  Hemiplegia — 
Peripheral  Arteries — Variation  of  Symptoms — Differentiation  between  Embolism 
and  Cerebral  Hemorrhage — Differentiation  between  Thrombosis  and  Embolism — 
Symptoms  of  Anaemia  from  Collateral  (Edema — Obscure  Diseases  explained  by 
Collateral  (Edema— Explanation  of  Phenomena  of  Clot — Symptoms  of  Pressure 
by  Abscesses,  Tumors,  etc. — Obscurity  of  Diagnosis  in  Brain-Diseases — Views  of 
Charcot,  Cohnheim,  Heubner,  and  Duret  upon  the  Terminal  Cerebral  Arteries — 
Charcot's  Recent  Teachings  upon  the  Pathological  Anatomy  of  Cerebral  Soften- 
ing     57 

7 


8  CONTENTS. 

LECTUKE    lY. 

GENERAL   CEREBRAL   ANEMIA. 

PAGE 

Symptoms — Diagnosis — Treatment 87 

LECTUEE    V. 

MENINGITIS. 

Acute  Idiopathic  Meningitis,  or  Leptomeningitis — Pachymeningitis — Tubercular 
Meningitis — Cerebro-Spinal  Meningitis — Simple  Idiopathic  Meningitis — Chronic 
Meningitis — Characters — Symptoms  :  Chill,  Fever,  Headache,  Delirium — Vomit- 
ing, Constipation  —  First  Stage — Second  Stage — Pericarditis — Pneumonia — 
Rheumatism — Typhus  and  Typhoid  Fevers — Syphilis — Hydrocephaloid — Prog- 
nosis— Causes — Convulsions  in  Children — Treatment :  Drastic  Purgatives,  Cold 
Applications,  Ergot,  Bromide  and  Iodide  of  Potassium,  Vesicants,  Venesection, 
Leeches,  Cupping,  Counter-irritants 99 

LECTUEE    VI. 

TUBERCULAR    MENINGITIS. 

Acute  Idiopathic  Meningitis — Anatomical  Lesions  a  Peculiarity — Acute  Hydro- 
cephalus— Symptoms  :  Period  of  Invasion,  Gradual  Impairment  of  Health,  Change 
of  Habits  and  Temper,  Headache — Importance  of  Cephalalgia — Stages :  Slow 
Pulse,  Suspirious  Respiration,  Cerebral  Maculae,  Boat-shaped  Abdomen,  Flush 
and  Pallor,  Cephalic  Cry,  Remission  in  Fever,  Increased  Somnolence,  Coma, 
Changes  in  Paralytic  Phenomena — Sources  of  Error  :  Bilious  Intermittent  Fever, 
Typhoid  Fever,  Hydrocephaloid  of  Marshall  Hall,  Partial  Anaemia — Optic 
Neuritis — Prognosis — Treatment — Koch's  Injections  in  Tubercular  Meningitis  .    110 

LECTUEE    VII. 

CEREBRO-SPINAL   MENINGITIS. 

Anatomical  Characters — Its  Nature — An  Essential  Fever — Malignant  Scarlet 
Fever — Malarial  Fevers — Three  Forms  :  Simple,  Fulminant,  and  Purpuric — 
Clinical  History — First  Form — Symptoms — Brain,  Spinal,  and  General :  Chills 
and  Fever, Vomiting,  Pain,  Decubitus— Second  Form — Third  Form — Reabsorbent 
Fever — Death  from  Asthenia  or  Coma — Generalities — Pathological  Anatomy — 
Prognosis — Treatment — Hygiene — Morphine  for  Rachialgia — Iodide  and  Bro- 
mide of  Potassium,  Fluid  Extract  of  Ergot,  Belladonna,  Quinine,  Salicylate  and 
Benzoate  of  Sodium 124 

LECTUEE    VIII. 

PACHYMENINGITIS. 

Forms  of  Meningitis — Pachymeningitis— Pachymeningitis  Externa— Pachymenin- 
gitis Interna  or  HaBmorrhagica — Etiology  :  Blows,  Injuries,  Ozsena,  Otorrhoea — 
Anatomical  Characters — Clinical  History — IlEematoma  of  the  Dura  Mater — In- 
flammation of  the  Cerebral  Sinuses — Thrombosis— Metastatic  Abscesses  in  the 
Lungs  —  Symptoms  —  Causes  of  Death — Treatment— Prognosis— Pathological 
Anatomy — Cranial  Surgery  in  Pachymeningitis 137 


CONTENTS. 


LECTUKE    IX. 

PAGE 
NEO-MEMBKANES   OF   THE   DURA   MATER.  153 


LECTUEE    X. 

GENERAL   MENINGEAL   HEMORRHAGE.  165 

LECTURE    XI. 

CHRONIC   CEREBRAL   MENINGITIS. 
Hammond's  Classification — Brown-Sequard's  Views,  etc 169 

LECTUEE    XII. 

INSANITY. 

Insanity  a  Disease  of  the  Brain — Its  Origin — Location — Predisposition — Insanity 
Hereditary — Definition — Unconscious  Cerebration — Moral  Insanity;  Examples 
— Rules  for  Ascertaining  Insanity 184 

LECTUEE    XII L 

INSANITY — continued. 

Classifications — Maudsley's  Classification — Etiology — Predisposing  Causes  :  Cli- 
mate, Religion,  Civilization,  Sex,  Period  of  Life,  Deficient  Education,  Individual 
Predisposition,  Insane  Temperament — "  Border-Land  of  Insanity" — Exciting 
Causes :  Masturbation,  Drunkenness,  Epilepsy,  Transmutation  of  Nervous 
Diseases,  Chronic  Diseases,  Disorders  of  the  Sexual  Functions,  Injuries  to  the 
Head — Moral  Causes 199 

LECTUEE    XIV. 

EMOTIONAL   INSANITY,   AND   ITS   MEDICO-LEGAL   RELATIONS.  211 

LECTUEE    XV. 

INSANITY — continued. — melancholia. 

Phenomena — "  Concrete  Form  of  Misery" — Difference  between  Melancholia  and 
Mania — Lypemania  and  Pantophobia — "  Furor  Melancholicus" — Hj'pochondri- 
acal  Melancholia,  Phenomena  of;  Case  of — Another  Form  of  Melancholia — 
Distention  and  Torpor  of  Colon — Tendency  to  Suicide — Melancholia  Attonita — 
Folic  Circidaire,  or  "  Circular  Insanity" — Paroxysmal  Violence  not  necessarily 
an  Evidence  of  Insanity — Affective  Form  rarely  absent — Moral  Treatment: 
Evil  Effects  of  Delay,  Beneficial  Efi"ects  of  Asylum  Treatment — Medical  Treat- 
ment :  Opium,  Aloetic  Laxatives,  Tonics,  Alcoholic  Stimulants,  Sulfonal  for  In- 
somnia, Rhamnus  Frangula,  Phenacetin  and  Citrate  of  Caffeine  in  Posterior 
Cervical  Pains  of  Melancholia,  Repression  of  Menstruation 240 


10  CONTENTS. 

LECTUEE     XVI. 

iisTSANiTY — continued. —  mania  —  monomakia    (paranoia). — dementia.  — 

MORAL    INSANITY. IDIOCY. — IMBECILITY. 

PAOE 

Acute  Delirious  Mania  ("  Typhomania"),  or  Delirium  Grave — Treatment — Mania : 
its  Characteristics,  Course,  Prognosis,  and  Treatment — Monomania  ("Paranoia") 
— Dementia,  Acute  and  Chronic — Moral  Insanity:  Diagnosis  of;  Illustrative 
Case — Idiocy — Moral  Imbecility — '•'  Linear  Craniotomy  in  Microcephalia" — 
"  Katatonia" — Hysterical  Insanity — Transitory  Insanity — Alcoholic  Insanity — 
Insanity  and  Bright's  Disease — Insanity  following  Influenza — Insanity  compli- 
cating Heart-Disease 251 

LECTUEE    XVII. 

EPILEPTIC   INSANITY   AND    ITS   MEDICO-LEGAL   RELATIONS  284 

LECTUEE    XVIIL 

GENERAL   PARALYSIS   01'   THE   INSANE. 

History — Etiology — Symptomatology — Diagnosis — Prognosis — Pathological  Anat- 
omy— -Treatment — Cerebral  Surgery  in  General  Paralysis 303 

LECTUEE    XIX. 

DIAGNOSIS   01"   INSANITY   IN   GENERAL. 

Diagnosis  of  Insanity  in  General — Cautions  necessary  in  Determining  Insanity — 
Simulated  Insanity — Tests — Simulation  of  Insanity  by  the  Insane — Prognosis 
of  Insanity — Pathology  and  Anatomical  Appearances  of  Insanity — The  Frontal 
Lobes  are  the  Seat  of  Intellect — Lesions  of  Frontal  Lobes  produce  Changes  of 
Character — Recapitulation — Brain-Surgery  in  Insanity — Comparative  Advan- 
tages of  Home  and  Asylum  Treatment 325 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


LECTUEE  I. 

THE   CEEEBEAL  CIBCULATION. 

GEiSTTLEiiEisr, — Variations  of  the  quantity  of  blood  in  the 
brain  may  take  place  under  many  conditions.  The  cerebral  sub- 
stance is  enveloped  by  three  membranes.  The  dura,*  which  is 
outermost,  furnishes  certain  folds  or  prolongations  to  form  the  so- 
called  cerebral  sinuses,  which  are  lined  by  the  continuation  of  the 
serous  membrane  of  the  veins,  and  convey  the  venous  blood  from 
the  brain.  The  innermost  membrane,  the  pia,  is  the  vascular  mem- 
brane, and  from  it  most  of  the  arterial  supply  finds  its  way  into 
the  substance  of  the  brain  by  the  capillary  vessels.  The  inter- 
mediate membrane  is  the  arachnoid,  which  is  reflected  upon  itself, 
the  space  between  the  folds  constituting  its  cavity.  This  latter 
membrane  does  not,  like  the  pia,  follow  the  surface  of  the  cere- 
brum into  its  depressions  or  sulci,  but,  on  the  contrary,  stretches 
across  the  depressions,  and  leaves  between  itself  and  the  pia  a 
space  called  subarachnoid,  which  contains  a  liquid, — the  cerebro- 
spinal fluid.  The  amount  of  this  fluid  in  the  cranial  cavity  is 
not  constant,  but  is  in  inverse  ratio  to  the  amount  of  blood  in  the 
vessels. 

In  this  connection  the  student  should  remember  that  the  deep 
lymphatics  of  the  cranium,  according  to  Gray,  consist  of  two  sets, 
the  meningeal  and  the  cerebral. 

*  At  a  recent  congress  of  European  neurologists  it  was  decided,  among 
other  changes  in  nomenclature,  to  drop  the  word  mater,  using  simply  the 
words  dura  and  pia. 

11 


12  DISEASES   OF   THE   NEKVOUS   SYSTEM. 

"  The  meningeal  lymphatics  accompany  the  meningeal  vessels, 
escape  through  foramina  at  the  base  of  the  skull,  and  join  the 
deep  cervical  lymphatic  glands.  The  cen-ehral  lymphatics  are  de- 
scribed by  Eshmann  as  being  situated  between  the  arachnoid  and 
pia,  as  well  as  in  the  choroid  plexuses  of  the  lateral  ventricles : 
they  accompany  the  trunks  of  the  carotid  and  vertebral  arteries, 
and  probably  pass  through  foramina  at  the  base  of  the  skull,  to 
terminate  in  the  deep  cervical  glands.  They  have  not  at  present 
been  demonstrated  in  the  dura  or  in  the  substance  of  the  brain.'' 

The  perivascular  canals  are  conduits  formed  by  the  pia  around 
the  vessels  of  the  brain. 

The  perivascular  lymphatics  are  lymphatic  vessels  or  plexuses 
ensheathing  blood-vessels. 

The  perivascular  sheath  is  a  sheath  of  pia  forming  a  perivas- 
cular canal. 

The  perivascular  spaces,  or  "Virchow-Robin's  spaces,"  are 
lymph-spaces  bet^veen  the  outer  and  middle  coats  of  an  artery.* 

In  the  study  of  cerebral  circulatory  disturbances,  the  influence 
of  the  perivascular  spaces  is  not  so  clearly  understood  as  we  might 
wish.  That  they  and  their  contents  participate  in  the  phenomena 
of  congestion  cannot  be  doubted. 

A  greater  flow  of  blood  in  the  arterioles  is  necessarily  accom- 
panied by  increased  afflux  in  the  above-mentioned  conduits,  with 
corresponding  augmentation  of  the  amoeboid  movements. 

This  view  is  corroborated  by  Yirchow's  assumption  "  of  the 
existence  of  diffusive  currents  (endosmosis  and  exosmosis)  between 
the  contents  of  the  vessels  and  the  fluid  in  the  tissues ;  and  by 
regarding  the  capillary  wall  as  a  more  or  less  indifferent  mem- 
brane, forming  merely  a  partition  between  two  fluids,  which  enter 
into  a  reciprocal  relation  with  one  another ;  while  the  nature  of 
this  relation  would  be  essentially  determined  by  the  state  of  con- 
centration they  are  in  and  their  chemical  composition,  so  that, 
accordino;  as  the  internal  or  the  external  fluid  was  the  more  con- 
centratcd,  the  diffusive  stream  would  run  inwardly  or  outwardly, 
and  according  to  the  chemical  peculiarities  of  the  individual 
juices,  certain  modifications  would  arise  in  these  currents." 

In  this  connection  I  must  again  quote  Virchow,  to  the  effect 

*  For  these  detinitions  see  Billings,  Nat.  Med.  Diet.,  1890. 


THE   CEREBRAL   CIRCULATION.  13 

that  "  we  must  not,  however,  go  so  far  as  to  ascribe  to  this  mem- 
brane all  the  peculiarities  observable  in  the  interchange  of  ma- 
terial, and  so  explain  how  it  happens  that  certain  matters  which 
enter  into  the  composition  of  the  blood  are  not  distributed  in 
equal  proportion  to  every  part,  but  leave  the  vessels  at  some  points 
in  greater,  at  others  in  less  quantity,  and  at  others  not  at  all. 
These  peculiarities  depend,  manifestly,  on  the  one  hand,  upon 
the  different  degrees  of  pressure  to  which  the  column  of  blood  is 
subjected  in  certain  parts,  and,  on  the  other,  upon  special  proper- 
ties of  the  tissues ;  and  we  are  irresistibly  compelled,  both  by  the 
consideration  of  simply  pathological,  and  particularly  by  that  of 
pharmaco-dynamical  phenomena,  to  admit  that  there  are  certain 
affinities  existing  between  definite  tissues  and  definite  substances, 
which  must  be  referred  to  peculiarities  of  chemical  constitution, 
in  virtue  of  which  certain  parts  are  enabled  in  a  greater  degree 
than  others  to  attract  certain  substances  from  the  neighboring 
blood." 

I  would  observe,  therefore,  that,  notwithstanding  the  usual 
contents  of  the  perivascular  spaces,  at  times,  under  the  influence 
of  circulatory  disturbances,  more  or  less  cerebro-spinal  fluid  will 
be  directed  thereto  :  hence  the  philosophy  of  the  cerebral  circula- 
tion would  not  be  complete  without  a  reference  to  their  relation- 
ship to  it. 

Gowers,  in  his  "  Diseases  of  the  Nervous  System,"  observes 
upon  this  subject,  "  It  was  at  one  time  thought  that  the  blood 
in  the  brain  could  not  vary  in  amount,  because  the  cranio- verte- 
bral cavity  is  a  closed  space,  and  this  opinion  is  still  occasionally 
put  forward.  But  the  mobility  of  the  cerebro-spinal  fluid  (which 
occupies  not  only  the  inter-membranous  space  and  the  ventricles,  but 
also  the  lymphatic  spaces  around  the  vessels)^  permits  the  vascular 
distention  to  vary.  If  the  cavity  were  hermetically  closed,  the 
variation  could  be  only  relative,  not  absolute.  But  the  numerous 
foramina  of  the  cranium  and  vertebral  canal  are  occupied  by  less 
resistant  structures,  which  no  doubt  may  yield  in  some  degree. 
Moreover,  the  large  surface  veins  of  the  spinal  cord,  and  still 
more  the  enormous  plexus  outside  the  spinal  dura,  doubtless 
constitute   an   important  means   of   adaptation.      Further,   the 

*  Italics  my  own. 


14  DISEASES   OP   THE   NEEVOUS  SYSTEM. 

processes  of  secretion  and  absorption  of  the  cerebro-spinal  fluid, 
always  in  constant  operation,  must  be  influenced  by  the  degree  of 
pressure,  and  may  quickly  vary  with  it.  Although  the  conditions 
during  life  and  after  death  are  widely  different,  yet  we  may  reason- 
ably regard  the  enormous  variations  in  the  total  amount  of  blood 
within  the  cranio-vertebral  canal  after  death  in  different  cases  as 
evidence  that  considerable  variations  may  occur  during  life.  Some 
variation  is  physiological.  In  the  child,  before  the  fontanelles 
are  closed,  and  in  the  adult  when  a  piece  of  the  skull  is  removed,* 
it  is  seen  that  the  brain  pulsates  synchronously  with  the  heart, 
and  that  variations  also  result  from  the  respiratory  movements  of 
the  thorax.     Tracings  of  these  movements  have  been  obtained." 

Tuke  t  thinks  that  "  the  importance  of  the  lymphatic  system 
of  the  encephalon  as  a  factor  in  morbid  processes  has  been  too 
much  overlooked." 

In  connection  with  this  subject,  and  in  corroboration  of  the 
views  I  have  presented,  I  quote  the  following  observations  from 
a  thesis  sustained  before  the  Faculte  de  M^ecine  of  Paris,  en- 
titled "  Contribution  k  I'Stude  de  I'Enc^phalocele  acquise,"  by 
Dr.  Lewis  A.  Lebeau,  of  St.  Louis,  in  1875 :  "In  the  normal 
condition  the  brain  is  contained  in  the  cranial  cavity  and  sus- 
pended, as  it  were,  in  the  midst  of  the  cephalo-rachidian  liquid, 
which  fills  the  void  which  occurs  when  the  sanguineous  afflux 
diminishes  in  the  nervous  centres ;  the  different  parts  of  the  en- 
cephalic mass  are  enclosed  in  the  folds  of  the  dura  mater,  and 
cannot  therefore  be  compressed ;  the  entire  mass,  it  is  true,  is 
enclosed  in  an  incompressible  cavity,  but  a  part  of  its  contents  can 
escape  when  cerebral  congestion  occurs ;  there  exists  a  constant 
relation  between  the  quantity  of  blood  which  enters  therein  with 
every  cardiac  systole  and  the  cerebro-spinal  fluid  correspondingly 
displaced.  At  the  same  time  it  is  important  to  remember  that 
there  exists  the  passive  stasis  of  blood  in  the  cerebral  veins  during 
forced  expiration,  and  during  all  muscular  efforts  associated  with 
the  physiological  efforts  which  excite  these  respiratory  acts. 

"  There  is  an  embarrassment  of  the  returning  circulation,  the 

*  "  In  an  operation  that  I  recently  witnessed  (removal  of  a  tumor  from  the 
spinal  cord),  before  the  dura  was  opened  its  distention  with  every  movement 
of  respiration  was  most  conspicuous." — Oowers,  Dis.  Ne7-v.  Syst,  ed.  1888. 

t  Ann.  TJniv.  Med.  Sci.,  Sajous,  1891. 


THE   CEREBRAL   CIRCULATION.  15 

blood  in  the  jugular  veins  is  prevented  from  emptying  into  the 
right  auricle  and  produces  a  mechanical  obstacle  to  a  free  flow  of 
the  blood  in  the  cerebral  veins,  pronounced  stasis  and  turgescence 
therefore  follow ;  in  both  cases  there  is  a  corresponding  augmen- 
tation of  the  volume  of  the  brain,  but  in  the  first  instance  the 
arterial  pressure  is  not  continuously  sustained,  but  the  cardiac 
pulsations  do  not  cease.  In  the  second  case  there  is  a  mechanical 
engorgement  which  persists  as  long  as  the  pulmonary  cause  which 
produces  it  lasts.  Venous  stasis  of  the  brain  is  very  rea,dily  pro- 
duced, as  the  jugular  veins  have  insufficient  valves ;  in  this  con- 
nection it  should  be  stated  that  Mr.  Guyon  considers  that  the 
thyroid  gland  exercises  a  compression  upon  these  vessels,  thereby 
preventing  an  increased  flow  of  blood  to  the  brain,  and  conse- 
quently diminishes  the  engorgement  of  that  organ. 

"Messieurs  Pelletan  and  Bourgougnon  adopted  the  extreme 
view,  in  consideration  of  the  fact  of  the  incompressibility  of 
liquids,  that  the  brain  does  not  pulsate,  notwithstanding  the  un- 
questionable existence  of  arachnoidean  pulsation.  Schlichting, 
Lorry,  Lamure,  in  their  memoirs  in  the  Academy  of  Sciences, 
and  Haller,  in  his  Opera  Minora,  recognized  and  demonstrated 
the  incontestable  pulsation  of  the  brain.  Moreover,  Monsieur 
Richet  taught,  in  his  work  on  Surgical  Anatomy,  that  a  con- 
tinual afflux  and  reflux  of  the  cerebro-spinal  fluid  existed  between 
the  cranial  and  arachnoidean  cavities ;  he,  moreover,  claimed  that 
the  rachidian  cavity  was  to  a  certain  extent  an  '  escape-tube' 
which  permitted  the  brain  to  become  engorged,  and  just  in  pro- 
portion as  its  volume  is  augmented  the  more  will  the  liquid  in  the 
spinal  canal  be  expelled ;  moreover,  the  cerebro-spinal  fluid  is 
never  the  same  in  quantity  :  its  quantity  varies  from  day  to  day 
and  accumulates  in  proportion  to  the  space  existing  in  the  en- 
cephalic cavity. 

"  Nevertheless,  the  cerebral  engorgement  does  not  pass  a  certain 
limit ;  when  in  the  physiological  condition  the  maximum  cerebral 
congestion  is  attained,  there  nevertheless  remains  a  small  quantity 
of  the  cerebro-spinal  fluid  between  the  brain  and  the  cranial  bones ; 
but  this  condition  is  not  the  same  in  pathological  cases  ;  the  pen- 
etration of  air  into  the  midst  of  the  arachnoidean  cavity  prevents 
the  approximation  of  its  respective  folds,  capillary  circulation 
ceases,  and  the  cerebro-spinal  fluid  flows  towards  the  base  of  the 


16  DISEASES   OF   THE   NERVOUS  SYSTEM. 

brain ;  in  fact,  in  no  case  is  the  presence  of  this  fluid  noticed  in 
fractures  of  the  vault  of  the  cranium ;  on  the  other  hand,  it  is 
one  of  the  signs  of  fractures  at  the  base  of  the  skull ;  the  local 
afflux  of  arterial  blood  is  thus  augmented,  and  it  is  easily  com- 
prehended that  there  may  be  a  more  or  less  considerable  engorge- 
ment at  the  points  where  the  osseous  structures  have  yielded,  and, 
in  consequence  of  the  little  resistance  of  the  brain  at  any  point 
of  the  cranial  vault,  the  cerebral  congestion  is  transmitted  to  the 
pia  mater,  finally  to  the  cranial  bones ;  these  conditions  are  some- 
what relieved  by  the  reflux  of  the  cerebro- spinal  fluid." 

Some  have  maintained  that  the  brain,  being  tightly  held  in  the 
closed  cranial  cavity,  will  not  admit  of  any  variation  in  the  quan- 
tity of  the  blood  therein  contained  unless  there  should  occur  an 
inverse  variation  in  the  quantity  of  its  solid  contents.  In  con- 
tradiction to  this  opinion,  the  theory  has  been  advanced  that  the 
cranial  cavity  is  not  absolutely  closed,  and  that  the  quantity  of 
blood  circulating  in  the  brain  may  be  augmented  by  cerebral  com^ 
pression,  the  result  of  which  would  necessarily  afibrd  increased 
capacity,  with  corresponding  reduction  of  volume. 

Were  the  cerebral  substance  strictly  compressible,  the  amount 
of  cerebro-spinal  fluid  might  actually  remain  constant ;  for  when 
a  larger  amount  of  blood  than  usual  found  its  way  into  the  brain, 
its  solid  constituents  would  simply  be  forced  to  occupy  a  smaller 
space. 

This,  however,  is  not  the  fact ;  and  although,  perhaps,  by  press- 
ure, you  might  bring  the  several  particles  of  the  brain  into  closer 
proximity,  you  could  not,  without  causing  molecular  disintegration, 
make  them  occupy  less  space  than  previously. 

The  brain  may  be  compared,  as  was  cleverly  suggested  by  Dr. 
Elam,  to  a  sponge  filled  with  fluid.  By  firm  pressure  you  can 
cause  all  of  the  latter  to  escape  from  the  porosities  of  the  formei'. 
You  can  make  the  sponge  apparently  smaller  than  it  was  before 
the  fluid  was  expressed,  but  it  is  impossible  to  reduce  its  volume 
absolutely  by  any  pressure  you  may  exert.  The  pores  which 
existed  in  its  substance,  it  is  true,  have  been  obliterated ;  but  the 
constituent  particles  of  the  solid  have  by  no  means  been  com- 
pressed into  a  smaller  space,  which  could  be  accomplished  only 
by  their  actual  encroachment  each  upon  the  other,  an  occurrence 
which,  if  possible,  would  doubtless  lead  to  their  ultimate  drSor- 


THE   CEREBRAL   CIRCULATION'.  17 

ganization.  Therefore,  as  Dr.  Elam  clearly  shows,  the  human 
brain  is  certainly  incompressible.  Dynamically  speaking,  how- 
ever, a  pressure  may  be  exerted  materially  influencing  this 
supreme  nerve-centre,  not  by  a  reduction  of  its  size,  but  by  pro- 
ducing unmistakable  effects  upon  its  molecular  structure  through 
the  active  circulation  of  blood  when  flowing  in  undue  quantities, 
and  under  a  variety  of  pathological  conditions,  in  its  delicate  and 
highly-organized  substance. 

Hence  vascular  tension,  occasioned  by  fluctuations  in  the  quan- 
tity of  the  cerebral  circulation,  becomes  an  important  factor  in 
the  explanation  of  many  of  the  phenomena  which  we  have  to 
study. 

We  can  readily  understand  that  fluxion  and  stasis  may  eventuate 
in  molecular  changes  profoundly  influencing  the  interstitial  nu- 
trition of  an  organ  so  remaAably  sensitive  and  impressionable, 
in  consequence  of  the  activity  of  its  physiological  tissue-metamor- 
phoses. This  blood-pressure  may  be  better  understood  if  we  con- 
sider Dr.  Elam's  illustration,  which  most  forcibly  struck  me  in 
reading  his  valuable  book.  He  states  that  "  glass  is  sufiiciently  in- 
compressible to  be  considered  altogether  so ;  yet  glass  may  be  sub- 
jected to  pressure,  and  the  effects  upon  its  molecular  structure  are 
very  striking  and  suggestive.  Even  the  slight  pressure  that  may 
be  exerted  by  the  fingers  is  sufficient  very  materially  to  alter  its 
optical  properties,  especially  as  to  its  relation  to  polarized  light ; 
and  the  change  continues  so  long  as  the  pressure  is  continued." 

It  may,  in  conclusion,  be  safely  affirmed  that,  while  the  quan- 
tity of  blood  circulating  in  the  cranial  cavity  may  undoubtedly 
vary,  the  sum  total  of  all  liquids  present  is  constantly  and  uni- 
formly the  same ;  which  fact  we  have  already  stated  is  explained 
by  the  inverse  ratio  of  compensation  existing  between  the  vital 
current  and  the  cerebro-spinal  fluid. 

In  a  word,  we  may  unequivocally  maintain  that  in  order  to 
change  the  relative  amount  of  cerebro-spinal  fluid  we  must  have 
an  increased  amount  of  blood  in  the  brain. 

The  blood  contained  within  the  cranial  cavity  is  thus  suscepti- 
ble of  notable  variations  of  its  volume,  while  in  quality  it  may 
be  affected  by  a  host  of  systemic  conditions. 

The  cerebral  circulation  plays  a  most  important  ?'d/e  in  the 
study  of  cerebral  congestion,  and  the  latter  in  all  conditions  in 

2 


18  DISEASES   OF  THE   NERVOUS  SYSTEM. 

which  as  a  primary  factor,  whether  active  or  passive,  it  produces 
serious  disturbances,  with  an  accompanying  train  of  morbid  phe- 
nomena. Secondary  congestions — a  result  of  a  multitude  of  vary- 
ing pathological  cerebral  lesions — are  of  no  less  interest,  and  offer 
the  only  reasonable  interpretation  of  numerous  fluctuating  symp- 
toms and  daily  mutations  in  the  condition  of  patients  affected 
with  cerebral  disease.  This  peculiar  variation  of  symptoms,  the 
daily  alternation  of  those  of  excitation  with  those  of  depression, 
the  appearance  and  disappearance  of  the  disturbances  of  motility 
within  a  few  hours  in  certain  cases,  may  be  thus  explained  satis- 
factorily. 

The  views  of  Schroeder  van  der  Kolk  upon  the  circulation  of 
the  brain  are,  I  think,  exceedingly  important,  and  I  therefore  pro- 
ceed to  quote,  on  this  subject,  from  his  work  on  the  Pathology  and 
Therapeutics  of  Mental  Diseases  : 

"To  rightly  understand  the  lesions  of  the  brain  in  mental 
diseases,  we  must  keep  in  mind  the  relation  of  the  circulation  to 
the  natality  of  the  brain.  It  is  evident  that  variations  of  intra- 
vascular pressure  of  the  blood,  and  of  its  arterial  or  venous  con- 
ditions, as  well  as  other  modifications  of  it,  cannot  remain  without 
important  influence  upon  the  brain. 

"  Daily  experience  teaches  us  that  violent  congestion  of  blood 
may  interrupt  the  functions  of  the  brain,  and  speedily  lead  to  a 
fatal  termination. 

"  "When  by  an  increased  activity  of  the  heart  the  blood  is  more 
powerfully  and  under  greater  pressure  driven  into  the  aorta,  it 
runs  off  for  the  most  part  and  quickest  through  those  vessels 
in  which  the  least  resistance  and  counter-pressure  have  to  be 
overcome. 

"  Let  us  now  remember  some  of  the  branchings  of  the  great 
vessels,  which  are  quite  remarkable.  In  the  first  place,  we  must 
recall  the  fact  that  the  inferior  thyroids  rise  close  to  the  vertebrals, 
and  that  at  the  division  of  the  common  carotid  into  the  internal 
and  external  carotids  the  superior  thyroid  is  given  off.  There  is 
undoubtedly  a  definite  purpose  to  be  attained  in  this  doubling  of 
the  thyroids  on  each  side  :  it  is  not  merely  to  secure  a  more  copious 
supply  of  blood  to  the  thyroid  gland,  for  the  latter  object  could 
have  been  very  readily  reached  if  either  of  the  two  thyroids  had 
received  a  greater  calibre.     The  thyroid  gland  can  take  up  a  large 


THE    CEREBRAL    CIECULATIOISr.  19 

quantity  of  blood,  and  is  capable  of  great  expansion,  since  For- 
neris  claims  to  have  ascertained  by  measurement  that  in  conse- 
quence of  its  expansion  the  neck  is  larger  during  sleep  and  on 
awaking  than  during  the  day.  Also  in  the  dead  body  the  size, 
the  consistence,  and  the  vascularity  of  this  gland  differ  remark- 
ably. We  may,  then,  assume  that  the  propelled  blood  finds  less 
resistance  in  the  two  extensile  thyroids  than  in  the  vertebrals 
and  internal  carotids,  which,  on  account  of  their  course  through 
long  canals,  can  increase  only  slightly  in  diameter  and  not  at  all 
in  length,  and  on  that  account  it  flows  off  in  greater  quantity 
towards  the  thyroid  gland.  Therefore,  with  its  other  functions, 
the  thyroid  may  be  regarded  as  a  diverticulum  or  reservoir  by 
which  a  too  strong  pressure  of  blood  may  be  diverted  from  the 
brain.  The  above-described  arrangement  of  these  arteries  is, 
moreover,  not  limited  to  mammalia.  According  to  J.  Simon,  the 
thyroids  of  the  bird  arise  exactly  opposite  the  place  where  the 
carotids  and  vertebrals  come  off,  and  even  in  amphibia  and  fishes 
these  vessels  stand  in  relation  with  the  vessels  of  the  brain. 

"  From  this  it  becomes  not  improbable  that  the  presence  of  a 
goitre,  which  receives  a  great  deal  of  blood  and  which  may  derive 
too  powerfully  from  the  brain,  induces  in  cretins  a  weaker  de- 
velopment of  the  brain,  or,  at  least,  a  debilitated  energy  of  it ; 
although  cretinism  is  not  to  be  regarded  as  a  product  of  goitre, 
but  is  frequently  concomitant  with  it.  It  is  well  known  that 
individuals  afflicted  with  goitre  are  frequently  dull  and  phleg- 
matic. It  is  probably  also  for  the  same  reason  that  sometimes  in 
meningitis  an  atrophied  thyroid  gland  is  found,  because  through 
this  condition  the  derivation  of  the  blood-stream  from  the  brain 
would  be  impeded,  which  then  led  to  repeated  congestions,  and 
contributed  to  the  development  of  meningitis. 

"  The  spreading  of  the  vessels  in  the  face  conduces  to  deriva- 
tion from  the  brain.  There  are  few  other  arteries  in  the  body 
so  readily  filled  with  blood  as  the  above,  because  they  are  every- 
where sm'rounded  by  soft  fat,  and  on  that  account  the  coats  of 
the  vessels  have  no  powerful  support  from  without.  Thence  it 
occurs  that  the  cheeks,  and  indeed  the  whole  face,  so  easily  assume 
an  increased  color  in  powerful  and  sudden  emotions,  especially 
also  from  high  degrees  of  temperature.  If  the  vessels  of  the 
brain  were  as  readily  filled,  apoplexy  from  every  active  exertion 


20  DISEASES   OF   THE   NERVOUS   SYSTEM. 

might  be  imminent.  The  external  carotid  artery  thus  leads  the 
strong  pressure  of  blood  outward,  because  the  internal  carotid  in 
the  closed  cavity  of  the  skull  cannot  equally  well  expand,  and  on 
that  account  opposes  a  more  powerful  resistance  to  the  blood- 
pressure.  We  cannot  always  conclude  from  diffused  redness  of 
the  face  that  there  is  congestion  of  the  brain,  although  the  latter 
is  frequently  associated  with  the  former. 

[Schroeder  van  der  Kolk,  in  a  foot-note,  here  states  that  the  researches  of 
Sucquet  corroborate  these  views.  He  has  demonstrated,  in  addition  to  the  proper 
capillaries,  larger  communicating  branches  between  the  arteries  and  veins  in 
the  hand  and  elbow,  in  the  foot  and  knee,— even  in  the  face,  in  the  skin  of  the 
lips,  nose,  eyelids,  eyebrows,  and  ears,  and  in  the  mucous  membrane  of  the 
cartilages  and  septum  of  the  nose.  He  correctly  claims  for  these  anastomoses 
a  derivative  purpose,  as  in  strong  arterial  pressure  the  blood  will  be  carried  on 
more  quickly  through  them  towards  the  veins.  In  old  age  these  communi- 
cating branches  increase  in  number  and  size.] 

"  Similar  conditions  occur  with  the  vertebrals.  These  arise  from 
the  subclavian  s,  and  with  strong  pressure  of  blood  the  stream  can 
be  derived  from  the  vertebrals  towards  the  arm.  For  this  reason 
may  hand-baths,  or  placing  a  bandage  around  the  arm  or  even 
the  finger,  stop  bleeding  from  the  nose  :  this  I  have  many  times 
experienced  with  the  best  effect,  and  in  earlier  years  was  accus- 
tomed to  verify  upon  myself. 

"  The  resistance  against  a  strong  blood-pressure  is  still  more 
increased  by  the  enclosure  of  the  brain  and  spinal  cord  in  bony 
cavities,  which  are  not  capable  of  extension,  and  which  under 
ordinary  circumstances  must  always  contain  the  same  volume  of 
solids  and  fluids,  as  no  elastic  structure  occurs  in  them.  Hence  it 
has  been  assumed  that  generally  no  increased  quantity  of  blood 
can  proceed  to  the  brain,  as  the  latter  is  not  capable  of  compres- 
sion. But  in  apoplexies  we  often  find  large  quantities  of  ex- 
travasated  blood. 

[Schroeder  van  der  Kolk  here  states  that  he  had  in  his  possession  a  prepara- 
tion where  the  blood  was  extravasated  in  so  great  quantity  between  the  dura 
and  the  skull  that  the  coagulated  mass  of  blood,  on  opening  the  skull,  was 
bigger  than  the  fist,  and  had  pressed  the  hemisphere  quite  flat.  The  blood  was 
freshly  coagulated  ;  its  extravasation  had  occurred  but  recently,  and  with  great 
rapidity,  so  that  death  must  have  been  immediate.] 

"Therefore  the  liquor  cerebro-spinalis  can  afford  room  for  a 
larger  quantity  of  blood,  while  it  escapes  out  of  the  cavity  of  the 


THE   CEREBRAL   CIRCULATION.  21 

skull  into  the  more  lax  and  movable  sac  of  the  dura  mater  spi- 
nalis, which  in  the  natural  condition  does  not  appear  to  be  full 
and  tense.  For  if  we  carefully  open  the  vertebral  canal  so  that 
the  dura  mater  is  not  injured,  the  sac  may  be  inflated  to  a  larger 
size.  For,  although  the  skull-cavity  is  not  thoroughly  unalter- 
able, the  blood-vessels  have  yet  a  stronger  support  from  it,  and  it 
opposes  a  stronger  resistance  to  too  great  filling  with  blood.  But 
a  certain  scope  is  indispensable,  as  every  exercise  of  power,  and 
consequently  also  activity  of  the  brain,  demands  a  more  active 
circulation  and  increased  change  of  material,  on  which  account  a 
powerful  and  continuous  mental  exertion  occasions  phenomena  of 
congestion,  and  at  last  induces  a  feeling  of  heaviness,  dulness,  and 
fatigue. 

"  Ivellie  claims  the  discovery  that,  on  account  of  closure  of  the 
skull,  the  blood  is  retained  in  its  cavity,  and  therefore,  after  fatal 
hemorrhage,  the  brain  does  not  appear  so  bloodless  as  the  other 
parts  of  the  body.  If,  on  the  other  hand,  through  preliminary 
trephining  he  permitted  the  entrance  of  air  into  the  cavity  of  the 
skull,  he  found  the  brain  also  bloodless.  Dieckenhoff,  however, 
could  not  corroborate  this  statement,  and  I  have  myself  found 
the  brain  quite  pale  and  bloodless  in  rapidly-fatal  hemorrhages. 
Nevertheless,  it  appears  to  me  that  Kellie's  assiunption  is  not 
entirely  to  be  rejected.  For  the  most  part  we  find  the  brains  of 
slaughtered  sheep  not  quite  bloodless.  But  if  the  vessels  of  the 
brain  become  emptied  through  hemorrhage,  the  space  must  be 
filled  by  something  else,  and,  according  to  Kellie,  it  is  by  serous 
exudation.  We  may,  however,  assume  that  in  a  rapidly-fatal 
hemorrhage  the  serous  fluid  runs  from  the  spinal  canal  into  the 
skull-cavity,  and  supplies  the  place  of  the  diverted  blood.  The 
space  forming  in  the  spinal  canal  must  then  be  balanced  by 
filling  and  distention  of  the  wide  vense  spinales,  which  veins 
communicate  with  the  vense  cephalicse  and  stand  in  reciprocal 
relation. 

"Nevertheless,  the  blood  will  be  retained,  if  not  completely, 
yet  longer  in  the  brain  than  in  any  other  organ. 

[Schroeder  van  der  Kolk  says  that  in  post-mortem  examinations,  when  the 
existence  of  brain-congestion  becomes  a  question,  we  must  bear  in  mind  the 
suction-power  exerted  on  the  blood.  The  brain  and  brain-fluids  contract  on 
cooling  of  the  body,  and  the  blood  in  the  veins,  which  still  remains  fluid 


22  DISEASES   OF   THE   NERVOUS   SYSTEM. 

several  hours  after  death,  is  partly  driven  hack  to  the  hrain  in  order  to  fill 
the  space  formed  through  its  shrinking.  Nasse  has  already  pointed  this  out. 
Thence  also  may  it  arise  that  the  hlood  in  the  veins  of  the  hrain  is  mostly  not 
coagulated,  because  the  fibrin  remains  behind,  and  only  the  fluid  blood  re- 
turns into  the  cavity  of  the  skull ;  therefore,  in  sections,  the  filling  of  the 
vessels  of  the  brain  gives  no  accurate  measure  of  their  condition  during  life.] 

"  In  lessened  blood-pressure,  after  copious  loss  of  blood,  a  more 
active  exudation  of  serum  may  easily  occur ;  and  tliis  explains 
why  abstraction  of  blood  operates  so  deleteriously  in  the  insane, 
especially  in  melancholic  patients.  If  serum  is  once  exuded,  it 
opposes  a  more  active  circulation,  the  brain  remains,  therefore, 
longer  ansemic,  and  softening  of  the  brain  and  imbecility  may  be 
induced  by  the  exuded  serum.  This  frequently  happens  in  such 
cases  after  venesection. 

"  Strong  pressure  of  blood,  resulting  in  distention  of  the  vessels 
of  the  brain,  as  is  often  the  case  in  chronic  insanity,  does  not  pre- 
clude the  passing  off  of  the  superabundant  blood  in  other  ways. 
If  the  blood  in  the  skull-cavity  is  under  a  stronger  pressure  than 
in  the  face,  it  has  an  outlet  through  the  ophthalmic  arteries,  and 
the  nose  and  the  supraorbital  region  through  the  frontal  artery 
acquire  a  deeper  color.  If  the  congestion  has  a  more  chronic 
course,  as  in  many  cases  of  acute  mania,  then  only  the  tip  of  the 
nose  is  more  deeply  colored.  But  the  same  also  occurs  in  melan- 
cholic patients.  Hence  we  also  observe  in  confirmed  tipplers,  in 
whom  for  the  most  part  habitual  brain- congestion  exists,  a  red  or 
bluish  swollen  nose.  As  the  ophthalmic,  through  the  anterior  eth- 
moidal artery,  extends  along  the  septum  narium  as  far  as  the  tip 
of  the  nose,  and  likewise  the  skin  of  the  nose  externally  is  in 
connection  with  twigs  of  the  ophthalmic  and  angular,  we  may 
easily  comprehend  how  it  is  that  the  ophthalmic  is  diagnostically 
so  significant,  if  the  blood  sustains  a  stronger  pressure  in  the 
cavity  of  the  skull  and  partly  flows  off  through  the  ophthalmic. 

"  We  have  in  the  color  of  the  sclerotic  an  entirely  uncertain 
sign.  Its  vessels  appear,  in  cerebral  irritation,  sometimes  to  con- 
tract under  the  influence  of  the  ciliary  nerves ;  at  least,  I  have 
myself  observed  the  sclerotic  still  white  in  very  intense  cerebral 
congestion  of  several  days'  duration,  and  in  apoplexy. 

"Bleeding  from  the  nose  is  a  favorable  event  in  congestions 
of  the  brain.  If  it  does  not  occur,  we  apply  a  leech  in  the  nose, 
from  which  I  have  several  times  seen  the  best  results. 


THE   CEREBEAL   CIRCULATION.  23 

[Our  author  states  that  he  has  frequently  injected  the  ophthalmic  alone  in 
the  skull-cavity.  The  forehead,  the  tip  of  the  nose,  and  the  cheek  were  colored 
thereby.  ] 

"  The  vertebral  arteries  before  they  enter  the  cavity  of  the  skull 
give  off  muscular  branches  which  communicate  with  the  posterior 
auricular.  It  is  due  to  this  fact  that  children  frequently  before 
convulsions  have  the  ears  reddened.  In  some  maniacal  patients 
the  nose  is  colored,  and  in  others  the  ears,  which  is  to  be  explained 
as  follows :  in  the  first  the  congestion  occupies  the  anterior  por- 
tions of  the  brain,  in  the  latter  the  posterior  portions.  It  is 
for  this  reason  that  in  congestions  and  in  epilepsy  repeated  cup- 
pings in  the  neck  act  favorably. 

"  The  deeper  color  of  the  lower  eyelid  acquires  a  decided  diag- 
nostic value  as  it  occurs,  for  example,  in  the  climacteric  years,  or 
sympathetic  with  uterine  diseases ;  especially  is  this  the  case  when 
other  diajmostic  signs  of  venous  congestion  occur. 

"  It  might  appear  as  if  the  firmness  of  the  vessels  of  the  brain 
were  impaired  by  their  walls  being  thinner ;  but  the  walls  of 
the  vessels  seem  to  be  thinner  rather  for  the  purpose  of  avoiding 
rupture  of  the  capillaries.  The  middle  muscular  coat  is  almost 
entirely  wanting ;  through  its  contraction  the  blood  experiences  a 
stronger  pressure,  and  is  driven  into  the  smaller  vessels ;  but,  on 
the  other  hand,  the  inner  and  outer  coats  of  the  vessels  afford  to 
the  latter  their  proper  firmness  and  power  of  resistance.  From 
absence  of  the  muscular  coat,  the  w^alls  of  the  vessels  yield  more 
easily  to  the  stream  of  blood,  offering  less  resistance  to  it,  and 
also  driving  the  blood  with  less  force  through  the  capillaries, 
which  in  the  brain  are  so  delicate  and  receive  so  little  support 
from  without.  The  consequence  of  this  is  a  more  even,  not  pul- 
satory, stream  of  blood  in  the  capillaries  of  the  brain.  For, 
while  the  larger  vessels  which  form  numerous  anastomoses  run 
a  considerable  distance  on  the  pia  mater,  although  on  account  of 
their  easy  distensibility  they  readily  yield  to  each  stroke  of  the 
pulse  by  reception  of  the  inflowing  blood-wave,  no  pulsation  is 
conveyed  to  the  smaller  vessels  of  the  brain  by  them.  In  this, 
also,,  may  be  sought  the  significance  of  the  rete  mirabile  which 
occurs  in  the  skull-cavity  of  many  mammalia, — namely,  in  the 
ox,  sheep,  and  deer. 

"  The  pia  mater  covers  the  cerebral  convolutions,  and  from  its 


24  DISEASES   OF   THE   KERVOUS   SYSTEM. 

imder  surface  very  fine  capillaries  pass  into  the  gray  substance, 
where  they  inosculate  freely  and  then  pass  into  fine  veins, 
which  again  return  to  the  pia  mater,  and  here  unite  into  larger 
branches.  Now,  if  the  blood  in  the  vessels  of  the  pia  mater,  in 
order  to  pass  into  the  veins,  must  all  go  through  the  cortical  layer 
of  the  convolutions,  every  more  active  determination  of  blood, 
for  example,  even  in  any  violent  movement,  must  immediately 
manifest  itself  in  so  easily  excitable  a  cortical  layer.  But  that  is 
not  the  case,  and  for  this  reason,  that  in  the  pia  mater  itself 
a  free  communication  exists  between  the  arteries  and  the  veins, 
of  Avhich  I  have  convinced  myself  by  means  of  injections. 

"  Thus,  in  a  violent  congestion  the  blood  for  the  most  part 
passes  away  over  the  cortical  layer,  without  acting  on  this,  into 
the  veins ;  the  storm,  as  'it  were,  sweeps  away  over  us  without  our 
perceiving  it.  However,  the  effect  of  such  a  congestion  always 
makes  itself  known. 

"The  cells  in  the  cortical  substance  are  at  the  moment  in  a 
condition  of  too  great  excitement ;  the  ideas  and  images  chase  one 
another,  and  are  not  under  control ;  deeper  reflection  requires  a 
previous  calming  of  the  circulation.  If  the  rapidity  and  strength 
of  the  circulation  increase  still  more,  as  sometimes  in  fever,  then 
delirium  may  be  reached  ;  the  involuntary  ideas  and  images  gain 
in.  strength,  so  that  they  are  no  longer  to  be  distinguished  from 
real  impressions. 

"Further,  due  regard  should  be  bestowed  upon  the  sinuses 
of  the  dura  mater,  which  are  not  capable  of  distention.  If  by 
impeded  respiration  the  outflow  of  blood  from  the  jugular  veins 
into  the  chest  is  hindered,  the  accumulation  of  blood  in  the  skull 
nevertheless  meets  a  resistance,  on  the  one  side  from  the  closure  of 
the  skull  itself,  on  the  other  because  the  sinuses  cannot  expand ; 
by  means  of  the  numerous  anastomoses  between  the  vense  spinales 
and  the  azygos,  the  blood  can  then  collect  more  in  the  abdomen. 

"The  brain  floats  in  the  cerebro-spinal  liquid  almost  as  in  a 
bath,  so  that,  according  to  the  researches  of  Poltz,  it  presses  on  the 
base  of  the  skull  with  only  one-fiftieth  of  its  weight.  Remember 
that  the  arteries,  which  on  account  of  their  power  of  expansion  can 
endure  a  greater  pressure,  all  lie  on  the  base  of  the  skull,  but  the 
easily-compressed  veins  are  collected  on  the  surface  of  the  hemi- 
spheres, and  have  their  position  mostly  in  furrows  between  the 


THE   CEREBRAL   CIRCULATION.  25 

cerebral  convolutions,  so  that  they  are  not  compressed  by  turgidity 
of  the  brain,  and  consequently  the  flow  of  blood  back  from  the 
brain  remains  as  free  as  possible.  Moreover,  between  the  branches 
of  the  arteries,  as  well  as  between  the  veins,  numerous  anasto- 
moses are  everywhere  found,  and  with  increased  flow  of  blood  no 
violent  congestion  of  the  brain  can  occur,  because  the  pressure 
is  divided  equally  on  all  the  arteries  and  veins.  Without  this 
disposition  a  stronger  flow  of  blood  through  one  of  the  cerebral 
arteries  would  immediately  have  as  a  consequence  a  stronger 
congestion  in  a  particular  section  of  the  brain,  through  which 
dangerous  extravasations  of  blood  would  easily  arise.  Now,  also, 
when  from  any  cause  the  flow  of  blood  is  cut  off"  at  one  place,  the 
blood  may  pass  through  lateral  branches,  so  that  the  circulation 
still  continues.  Nevertheless,  we  see,  in  embolism  of  the  vessels 
of  the  brain,  that  such  an  obstruction  may  be  very  deleterious  as 
soon  as  it  extends  over  a  rather  large  region. 

"  Through  all  these  harmoniously-combining  causes  it  becomes 
possible  that  the  brain  with  its  vessels,  notwithstanding  the  deli- 
cate structure  of  the  latter,  is  in  a  position  to  sustain  a  consider- 
able pressure.  We  see  this  in  difiicult  parturition,  in  asthma,  in 
whooping-cough,  in  epilepsy,  where  the  small  vessels  in  the  loose 
tissue  of  the  eyelids,  which  arise  from  the  ophthalmic  coming 
out  of  the  skull,  burst  in  consequence  of  the  great  congestion 
of  blood,  without  any  extravasation  occurring  in  the  brain  itself. 

"  We  owe  to  A.  H.  Durham  some  valuable  observations  on  the 
circulation  during  sleep.  It  was  formerly  supposed  that  in  sleep 
a  larger  quantity  of  blood  accumulated  in  tlie  brain,  and  that 
increased  venous  congestion  caused  the  coming  on  of  sleep. 
This  view  was  favored  by  increasing  sleepiness  in  plethora,  and 
also  by  the  accumulation  of  blood  in  coma,  and  by  the  occurrence 
of  sleep  after  an  epileptic  attack,  where  evidently  congestion  is 
present,  and  not  less  the  state  of  unconsciousness  in  apoplectic 
effusions  or  in  capillary  injections  of  the  vessels  of  the  brain. 
But  we  must  clearly  distinguish  tranquil  sleep  from  coma  and 
from  sopor.  A  portion  of  the  vault  of  the  skull  was  removed 
from  a  dog  with  the  trepliine,  and  then  the  underlying  dura 
mater  excised ;  the  uncovered  part  of  the  brain  appeared  to  press 
into  the  opening,  the  large  veins  on  the  surface  were  somewhat 
distended,  the  smaller  vessels  of  the  pia  appeared  to  be  full  of 


26  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

dark  blood,  and  no  decided  difference  of  color  between  arteries 
and  veins  could  be  perceived.  Such  was  especially  the  appear- 
ance and  condition  during  the  action  of  chloroform.  After  the 
action  of  the  chloroform  had  ceased,  the  animal  fell  into  a  com- 
paratively natural  and  sound  sleep ;  thereupon  the  surface  of  the 
brain  became  pale,  and  sank  rather  below  the  level  of  the  bone, 
the  veins  were  no  longer  distended,  little  vessels  having  an  arte- 
rial color  could  be  distinguished,  and  many  which  before  swelled 
with  dark  blood  could  no  longer  be  recognized.  When  after 
some  time  the  animal  was  awakened,  a  weak  red  color  appeared 
to  spread  over  the  surface  of  the  brain,  and  the  latter  again 
pressed  into  the  opening  in  the  bone.  The  more  active  the  dog 
was,  the  more  the  pia  became  injected,  and  the  more  turgid  was 
the  reddened  brain ;  everywhere  vessels  which  during  sleep  were 
not  visible  showed  themselves,  and  arteries  and  veins  could  be 
accurately  recognized  by  their  different  color.  The  animal  was 
now  fed,  and  then  again  sank  into  quiet  sleep ;  the  blood-vessels 
again  became  narrower,  and  the  surface  of  the  brain  pale  as  before. 
The  difference  in  these  appearances  was  the  more  firmly  estab- 
lished as  two  animals  under  opposite  conditions  were  observed. 
Lastly,  the  state  of  the  vessels  was  examined  with  a  strongly 
magnifying  lens,  and  also  under  weak  microscopical  power.  The 
trials  were  several  times  repeated,  with  exactly  similar  results. 
Dogs  were  found  to  be  more  suitable  than  rabbits. 

"  Atmospheric  pressure  could  have  exerted  no  influence  in  these 
experiments,  for  this  was  the  same  in  both  the  sleeping  and  the 
waking  state,  and  the  appearances  did  not  alter  when  accurately- 
fitted  glass  plates  were  set  in  the  skull-openings.  Durham  claims 
that  during  sleep  vascular  action  and  congestion  towards  the 
brain  exist  in  a  less  degree.  When  awake  and  when  the  brain  is 
active,  it  receives  more  blood,  Avhich  moves  more  rapidly  through 
the  vessels,  and  the  brain-substance  is  more  oxidized ;  for  the  func- 
tional activity  of  the  brain  demands  a  greater  consumption  of 
oxygen,  and  this  vis  a  f route  occasions  a  richer  supply  of  arterial 
blood,  enlargement  of  the  capillaries,  and  increased  change  of 
matter. 

"  The  increased  rapidity  of  the  circulation  causes  a  more  copious 
supply  of  oxygen,  and  probably  also  a  more  active  taking  up  of 
the  products  of  decomposition  into  the  blood.    If  fluids  are  allowed 


THE   CEREBEAL,   CIRCULATION.  27 

to  stream  through  a  rabbit's  intestine  which  lies  in  a  surrounding 
fluid,  the  quicker  the  stream,  the  less  fluid  will  transude  outward 
through  the  wall  of  the  intestine.  Now,  during  sleep  the  vis  a 
fro  ate  diminishes  ;  on  account  of  their  elasticity,  the  vessels  con- 
tract more,  and  the  nutritive  circulation  is  predominant ;  fewer 
blood-cells  circulate,  and  the  slowness  with  which  blood  flows 
favors  the  escape  of  nutritive  plasma. 

"  The  immediate  cause  of  temporary  suspension  of  cerebral 
activity  cannot  be  a  failure  of  active  material  or  its  exhaustion 
by  oxidation ;  for  the  already  fatigued  brain  may  be  brought  to 
renewed  activity  through  suitable  stimulation.  Durham  finds  this 
cause  in  the  products  of  decomposition,  and  appeals  to  the  obser- 
vation that  the  brain-substance  of  an  animal  just  killed  has  a 
neutral  or  even  a  slightly  alkaline  reaction,  but  shortly  after 
influence  of  the  atmosphere  is,  on  the  contrary,  acid.  Still, 
Heynsius,  before  Durham,  found  that  tlje  quite  fresh  brain  of 
the  sheep  or  of  the  ox  had  an  acid  rather  than  an  alkaline  reac- 
tion ;  this  was  confirmed  by  Funke,  who  at  the  same  time  ascer- 
tained that  in  increased  activity  of  the  brain  an  acid  reaction, 
and  in  inactivity  of  the  brain  an  alkaline  reaction,  is  present. 
Heynsius  has  ftirther  demonstrated  that  the  diffusion  or  exosmosis 
of  albumen  is  impeded  by  acid  and  is  promoted  by  alkali.  Thus, 
if  after  long  activity",  in  consequence  of  oxidation,  acid  has  accu- 
mulated in  the  brain,  less  albumen  transudes  out  of  the  blood- 
vessels ;  the  change  of  material,  or  rather  the  supply,  is  less,  and 
only  during  rest  can  the  acid  fluid  be  taken  up  and  carried  away, 
through  which  the  organ  then  becomes  fitted  for  renewed  activity. 
This  formation  of  acid  would  thus  be  a  corrective  of  over-irrita- 
tion or  immoderate  exertion  of  function.  According  to  Durham, 
acid  prevents  the  oxidation ;  according  to  Heynsius,  it  limits  the 
transudation  of  albumen.  Durham  thinks  that  the  nutrition  is 
increased  during  sleep ;  Heynsius  assumes  that  there  is  then 
increased  absorption  and  diminished  deposition  of  albimien,  con- 
sequently a  weakened  nutrition. 

"  To  me  it  appears  more  probable  that,  while  during  waking 
the  change  of  matter  is  increased,  with  which,  of  course,  a  greater 
supply  of  oxygen  as  well  as  of  albumen  must  be  combined  ;  during 
sleep,  on  the  contrary,  the  deposition  and  nutrition  are  more  active, 
whereby,  at  the  same  time,  the  acids  formed  are  carried  away. 


28  DISEASES   OF   THE   NERVOUS   SYSTEM. 

"  We  may  consider  that  sleep  arises  not  so  much  from  lessened 
supply  of  arterial  blood  as  from  diminished  change  of  matter, 
thus  from  diminution  in  the  supply  and  apposition  of  new  sub- 
stance. Diminished  supply  and  weaker  oxidation  may  also  occur 
if  in  derangement  of  the  circulation  the  vessels  are  considerably 
distended  with  blood,  and  if  from  powerful  resistance  the  circu- 
lation becomes  slow ;  the  renewal  of  the  blood  in  the  capillaries 
then  follows  too  slowly,  and  its  venosity  increases.  Coma  and 
sleepiness  thus  need  not  be  always  the  consequence  of  congestion 
and  sluggish  circulation ;  contraction  of  the  vessels  can  likewise 
induce  it,  as  well  as  a  lessening  of  the  oxidation  and  nutrition 
through  preceding  exertion  and  formation  of  acid  which  impedes 
nutrition.  The  essential  cause  in  both  cases  lies  in  a  lessening  of 
oxidation.  Thus,  also,  the  foetus  appears  to  be  in  a  lethargic 
condition  before  the  commencement  of  respiration,  so  long  as  its 
blood  is  only  weakly  arterial  and  oxidation  is  at  a  low  grade ;  only 
after  the  beginning  of  respiration  does  it  awaken  out  of  this  state, 
and  it  gives  evidence  of  this  by  half-voluntary  movements." 


LECTURE    II. 

aEXEEAL,  hypee^:mia  of  the  BEAZS". 

Definition — Active  Hyperemia/ — Causes  :  Emotions,  Fevers,  Diseases,  Slight  Resist- 
ance of  Capillaries,  Pressure,  Malaria,  Cold,  Atrophy  of  the  Brain,  Paralysis  of 
Yaso-Motor  Serves,  Alcohol,  etc. —  Irritation  of  Vaso-Motor  Nerves :  Poisons, 
Alcohol,  Excessive  Mental  Work — Passive  Hypersemia  —  Causes :  Strangulation, 
Pressure,  Expiratory  Efforts,  Impediments  to  the  Heart's  Action,  Compensation, 
Altered  Structure  or  Function  of  the  Lung  —  Post-Mortem  Changes  —  Active  Con- 
gestion— Anaemia  produced  by  Collateral  (Edema  —  Forms  of  Hyperaemia  —  Symp- 
toms of  Mild  Hypersemia — Severe  Form  —  Delirium — Insanity  —  Hallucination — 
Illusions — Apoplectic  Form — Common  Symptoms — Diagnosis — Prognosis — Treatment 
— Partial  Form  of  Hypersemia. 

Gextlemex, — Since  the  publication  of  the  first  edition  of  this 
work  in  1878  certain  authorities  have  expressed  doubts  regarding 
the  existence  of  cerebral  congestion,  and  would  seem  to  claim  that 
the  subject  is  barely,  if  at  all,  entitled  to  nosological  existence. 
Seguin,  of  New  York,  for  whose  writings  I  entertain  the  most 
profound  respect,  and  whose  opinions  we  shall  frequently  quote, 
in  a  recent  article  upon  the  "  Treatment  and  Management  of 
Neuroses"  states  that  "  the  condition  known  through  a  feat  of 
imagination  as  '  h}^er£emia  of  the  brain,'  which  has  been  quite  a 
prominent  figure  in  our  array  of  diseases  during  the  last  twenty 
years,  and  which  is  now  beginning  to  be  studied  and  reclassified- 
into  more  correct  clinical  types,  was  and  is  still  the  object  of 
treatment  by  the  free  use  of  bromides.  The  creation  of  the  '  dis- 
ease' was  mere  theorizing,  and  its  treatment  dictated  by  apparently 
logical  deductions  from  a  fanciful  premise.  We  know  that  many 
of  those  cases  which  provisionally  I  have  for  several  years  desig- 
nated as  '  paresthesia  about  the  head'  (the  most  common  s^Tup- 
toms  being  fulness,  tightness,  numbness,  emptiness,  and  some 
pain  in  the  head,  imperfect  sleep,  nervousness  and  hysteroid  con- 
ditions, flushing  of  the  face,  with  cold  extremities,  asthenopia, 
tinnitus  aurium,  apparent  loss  of  memory,  etc.)  are  really  depend- 
ent upon  eye-strain  (especially  those  in  which  occipito-vertical 

29 


30  DISEASES   OF   THE   NEEVOTJS   SYSTEM. 

symptoms  predominate),  lithsemia,  dyspepsia,  and  not  rarely  upon 
a  Tveak  heart  or  mitral  regurgitation.  The  time  has  not  come 
for  a  successful  or  final  analysis  of  this  S}Tnptom-group,  but  the 
belief  in  the  original  conception  of  its  hypersemic  nature  is  fast 
disappearing." 

GoTvers,  in  his  "  Diseases  of  the  Xer^^ous  System,"  also  makes 
the  following  comments :  "  Of  all  regions  of  cerebral  pathology, 
that  of  congestion  of  the  brain  is  perhaps  the  most  obscure.  We 
have  very  little  precise  knowledge  regarding  it,  and,  as  is  often 
the  case,  theory  has  flourished  in  proportion  to  the  deficiency  of 
fact.  It  was  long  thought  that  the  state  of  the  vessels  of  the 
brain  after  death  corresponds  with  their  condition  during  life,  and 
the  post-mortem  distention  was  accepted  as  a  proof  that  any  pre- 
ceding- cerebral  symptoms  were  due  to  congestion.  The  fact  was 
unobserved  or  ignored  that  a  similar  condition  of  the  brain  is 
equally  common  when  there  are  no  cerebral  symptoms  during  life, 
and  depends  chiefly  on  the  mode  of  death.  Hence  an  extensive 
symptomatology  was  elaborated  and  built  upon  an  erroneous 
foundation,  and  it  has  to  some  extent  survived  its  e^'idence. 
Moreover,  congestion  of  the  organs  seems  to  afford  so  satisfactory 
an  explanation  of  derangement  of  their  functions,  that  the  temp- 
tation to  assign  the  condition  as  the  cause  of  the  symptoms  has 
proved  irresistible  to  unscrupulous  practitioners.  In  this  way, 
also,  a  S}Tnptomatology  has  grown  up,  and  even  statistics  have 
been  amassed,  the  value  of  which  may  be  estimated  from  the 
fact  that  in  one  modem  text-book  the  history  of  cerebral  con- 
gestion has  been  manifestly  written  from  cases  of  pure  hypo- 
chondriasis. On  the  other  hand,  partly  by  a  reaction  from  this 
extreme,  some  have  doubted  even  the  possibility  of  the  condi- 
tion. The  truth  lies  between  the  two  extremes,  hut  its  precise  posi- 
tion icill  long  be  undetermined.^  Opportunities  of  ascertaining 
the  exact  pathological  condition  in  these  cases  are  \ev\  rare,  and, 
if  no  visible  lesion  is  found,  it  is  not  always  certain  that  the 
symptoms  obsers^ed  during  life  were  the  result  of  congestion. 
Hence  there  is  room  for  wide  difference  of  opinion,  even  among 
those  who  strive  to  keep  their  minds  unbiassed.  It  is  certain, 
however,  that  the  cases  in  which  symptoms  of  definite  character 

*  Italics  my  own. 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  31 

and  considerable  degree  can  be  reasonably  ascribed  to  this  cause 
are  far  from  frequent." 

Trousseau,  commenting  on  this  subject,  says,  "  The  existence 
of  cerebral  congestion  is  not  contested ;  but  it  has  been  singularly 
abused,  in  order  to  explain  cerebral  phenomena  in  the  production 
of  which  congestion  plays  no  part  whatever." 

I  must  say,  gentlemen,  that  I  cannot  myself  understand  mo- 
mentary congestions  of  the  brain,  which  play  so  great  a  part  in 
the  diagnosis  of  many  physicians.  But  this  does  not  impair  my 
faith  in  the  existence  of  hypersemia  of  the  brain,  nor  do  the  an- 
tagonistic views  of  eminent  authorities  influence  me  in  this  re- 
spect. In  fact^  I  believe  that  the  study  of  cerebral  hypersemia 
and  its  collateral  phenomena  constitutes  the  keystone  in  the  an- 
alysis and  explanation  of  the  greater  part  of  the  vast  domain  of 
cerebral  pathology. 

Notwithstanding  the  great  advance  of  neurological  knowledge 
in  the  last  decade,  we  still  claim  that  the  classic  views  of  Niemeyer 
on  this  subject  have  been  but  little,  if  at  all,  improved  by  recent 
writers,  and  we  therefore  will  still  adhere,  as  in  our  former  lec- 
tures, to  his  teachings  and  classifications  of  this  subject. 

I  have  said  that  cerebral  hypersemia  is  justly  entitled  to  noso- 
logical recognition.  This  statement  is  sustained  by  Spitzka,  as 
follows  :  "  While  this  change  in  our  views  is  the  natural  result  of 
progress  in  experimental  pharmacology  and  pathology,  it  does  not 
justify  the  extreme  assertion  that  there  is  no  disorder  of  the  brain- 
functions  deserving  the  name  of  congestion  and  hypersemia.  This 
assertion  seems  to  have  been  provoked  by  the  careless  manner  in 
which  these  terms  have  been  employed  to  designate  conditions 
which  are  in  reality  the  most  different  in  nature  that  can  be  well 
conceived.  No  one  familiar  with  the  extent  to  which  the  term 
'congestion  of  the  base  of  the  brain'  has  been  abused  in  this 
country  will  marvel  that  the  reaction  provoked  by  it  has  over- 
stepped the  boundaries  of  cautious  criticism.  That  there  are 
physiological  hypersemias  of  the  brain  is  now  universally  ad- 
mitted ;  the  most  recent  experimental  observations,  indeed,  con- 
form most  closely  to  tlie  claims  of  the  older  investigators.  It 
naturally  follows  that  pathological  hypersemias  are  both  possible 
and  probable,  and,  even  if  the  observations  in  the  dead-house  do 
not  strongly  sustain  the  existence  of  pathological  hypersemias  and 


32  DISEASES   or   THE   NEEVOUS   SYSTEM. 

congestions  independently  of  gross  disease,  clinical  analysis  and 
the  gratifying  results  of  appropriate  treatment  justify  us  in  re- 
taining these  designations  in  our  nomenclature  with  the  limitation 
here  implied." 

We  are  compelled  to  admit  that  some  of  Spitzka's  conclusions 
are  more  than  probably  correct,  in  view  of  some  of  the  older 
theories  of  the  etiology  of  congestion  of  the  brain,  especially,  for 
example,  as  induced  by  insolation.  Spitzka's  conclusions  in  some 
respects  agree  with  those  of  Niemeyer;  the  theories  of  older 
writers  are  at  variance  with  many  pathological  observations. 
Spitzka  observes  that  "  Arndt,  who  had  the  opportunity  of  study- 
ing over  one  hundred  cases  occurring  in  the  course  of  a  forced 
march  of  a  division  of  infantry  from  Berlin  to  Pankow,  many 
of  which  terminated  fatally,  found  almost  uniformly  a  pale  brain, 
with  peculiar  color-changes  denoting  rather  structural  than  circu- 
latory trouble." 

As  regards  the  effects  of  mental  overstrain  producing  cerebral 
hyper£emia,  Spitzka  quotes  Nothnagel  as  one  of  the  more  cautious 
writers  who  refuse  to  commit  themselves  to  the  view  that  the  re- 
sult of  mental  overstrain  is  a  simple  cerebral  hypersemia. 

In  an  important  foot-note,  Spitzka  makes  the  following  obser- 
vations :  "  It  has  repeatedly  happened  during  the  past  decade  that 
young  persons  competing  for  admission  to  higher  institutions  of 
learning  in  New  York  City  through  the  channel  of  a  competitive 
examination  died  with  symptoms  of  cerebral  irritation ;  the  death- 
certificates  in  several  such  cases  assigned  meningitis  or  cerebral 
congestion  as  the  cause  of  death,  and  attributed  the  disorder  to 
mental  overstrain.  It  is  not  so  much  the  intellectual  effort  that 
has  proved  hurtful  to  the  pupils  as  the  emotional  excitement  at- 
tending on  all  competitive  work,  the  dread  of  failure,  the  fear  of 
humiliation,  and  anxiety  developed  by  the  evident  futility  of  the 
cramming  process.  Some  years  ago  I  recorded  the  results  of 
some  inquiries  on  tliis  head  in  the  following  words  :  '  The  mental- 
hygiene  sensationalists,  who  periodically  enlighten  the  public 
through  the  columns  of  the  press  whenever  an  opportune  moment 
for  a  crusade  against  our  schools  and  colleges  seems  to  have  ar- 
rived, are  evidently  unaware  of  the  existence  of  such  a  disease  as 
delirium  grave,  and  ignorant  of  the  fact  that  the  disorder  which 
they  attribute  to  excessive  study  is  in  truth  due  to  a  generally 


GENERAL   HYPEE^MIA   OF   THE   BR  ATX.  33 

vitiated  mental  and  physical  state,  perhaps  inherited  from  a  feeble 
ancestry.  Our  school-system  is  responsible  for  a  good  deal  of 
mischief,  but  not  for  meningitis.'  (Insanity,  its  Classification, 
Diagnosis,  and  Treatment.)  Since  then  I  had  an  opportunity  of 
obtaining  an  excellent  description  of  such  a  case  which  had  been 
attributed  to  the  combined  effects  of  malarial  and  educational 
overstrain,  presenting  opisthotonos,  fulminating  onset,  and  an 
eruption  !" 

I  do  not  entirely  agree  with  Spitzka  when  he  maintains  that 
"  The  whole  list  of  causes  of  what  is  commonly  designated  cere- 
bral hyperaemia,  congestion,  and  engorgement  may  be  gone  through 
with  and  similar  modifying  statements  be  found  to  apply  to  them. 
The  nearest  approach  to  an  ideal  cerebral  congestion  is  that  found 
with  acute  alcoholic  intoxication."  (See  Spitzka  upon  "  Anaemia 
and  Hyperaemia  of  the  Brain  and  Spinal  Cord,"  Pepper's  System 
of  Medicine,  1886.) 

In  opposition  to  the  usual  rule  of  study  in  most  diseases,  it  is 
far  more  important  in  cerebral  hyperaemia  to  consider  the  etiology 
rather  than  the  semeiology  ;  this  is  apparent  for  two  reasons :  in 
the  first  place,  as  will  later  be  explained,  the  symptomatology  of 
cerebral  hyperaemia  is  analogous  to  that  of  cerebral  anaemia ;  and 
in  the  second  place,  it  is  only  by  the  study  of  extra-cranial  con- 
ditions that  we  can  possibly  understand  and  explain  the  phe- 
nomena of  cerebral  congestion.  By  hypercemia  is  meant  an  undue 
or  excessive  determination  of  blood  to  a  part.  Hyperaemia  of 
the  brain  is  generally  divided  into  two  kinds,  active  and  passive. 
By  active  hyperaemia  we  mean  arterial  or  acute  fluxionary  conges- 
tion. By  passive  hyperaemia  we  understand  venous  or  congestive 
hyperaemia. 

The  causes  of  hypercemia  are  numerous,  and  among  them  we 
find,  as  factors  of  acute  fluxionary  hyperaemia  : 

1.  Increased  cardiac  action  resulting  in  increased  capillary  con- 
gestion, the  arteries  under  these  circumstances  containing  more, 
the  veins  containing  less,  blood. 

2.  An  independent  cardiac  hypertrophy  is  another  cause  of  cere- 
bral congestion,  especially  when  the  former  state  is  not  compen- 
satory. The  latter  condition  is  more  particularly  found  in  alco- 
holism and  in  persons  subjected  to  excessive  muscular  exercise. 

3.  The  next  cause  of  acute  fluxionary  hyperaemia  I  fully  agree 

3 


34  DISEASES   OF   THE   NEEVOUS  SYSTEM. 

with  Niemeyer  results  from  "  too  slight  resistant  power  of  the  afferent 
blood-vessels/'  whether  this  be  congenital  or  acquired.  When  the 
cerebral  arteries  have  delicate,  thin  walls,  so  that  they  yield  to  an 
increased  pressure  of  the  blood  sooner  than  the  other  arteries  of 
the  body  do,  and  hence,  when  the  action  of  the  heart  is  only 
moderately  increased,  fluxionary  hypersemia  of  the  brain  is  in- 
duced, it  is  customary  to  say  that  the  person  so  affected  has  a 
tendency  to  "  rush  of  blood  to  the  head." 

4.  The  emotions  and  mental  excitement  are  also  factors  in  the 
etiology  of  cerebral  hypersemia.  We  have  all  experienced  the 
rush  of  blood  to  the  head,  preceded .  by  violent  throbbing  of 
the  heart,  and  followed  by  heat  in  the  upper  part  of  the  body, 
caused  by  violent  mental  emotions.  Ordinarily  these  emotions 
are  not  of  a  grave  nature,  and  consequently  their  effects  are  tran- 
sitory. It  happens,  however,  that  their  violence  may  be  such  that 
the  hypersemia  may  result  in  severe — nay,  fatal — consequences. 
Hypersemia  in  this  case  is  due  in  part  to  increased  cardiac  action 
and  partly  to  paralysis  of  the  vaso-motor  nerves. 

5.  Another  frequent  cause  of  hypersemia  is  fever,  which  pro- 
duces this  morbid  condition  by  increased  cardiac  action,  blood- 
poisoning,  and  excessive  elevation  of  temperature. 

6.  Certain  pathological  conditions  produce  hypersemia,  as  hyper- 
trophy of  the  left  ventricle  of  the  heart,  which  is  sometimes 
present  in  chronic  renal  disease,  and  non-complicated  and  over- 
compensatory  hypertrophy. 

7.  Undoubtedly  one  of  the  most  direct  causes  of  hypersemia  is 
pressure  by  tumors  upon  certain  portions  of  the  aorta.  Most  of 
the  blood  supplying  the  brain  being  carried  there  by  the  carotid 
arteries,  if  in  any  way  a  pressure  upon  the  thoracic  or  abdominal 
aorta  should  be  exercised,  it  is  evident  that  the  greater  volume  of 
blood  must  be  carried  upward,  and  consequently  to  the  brain, 
thus  giving  to  this  organ  an  undue  supply  by  increased  lateral 
pressure  in  the  carotids. 

8.  In  some  forms  of  malarial  poisoning  we  have  hypersemia 
during  the  algid  stage,  produced  by  diversion  of  the  blood  from 
the  peripheral  cutaneous  vessels  to  the  more>  deeply  situated 
organs  in  consequence  of  spasm  of  the  smaller  vessels.  It  fre- 
quently happens  that  extreme  cold,  in  this  manner,  becomes  a 
grave  cause  of  hypersemia.     The  explanation  in  this  case  is  ex- 


GENERAL    HYPEREMIA    OF    THE    BRAIN.  35 

tremely  simple.  We  all  know  that  cold  constringes  the  capilla- 
ries, and  consequently  produces  an  increased  current  to  the  inter- 
nal parts.  A  great  deal  of  this  blood  goes  to  the  brain,  and,  as 
it  is  arterialized,  it  irritates  tlie  nervous  system  and  produces 
symptoms  of  congestion.  As  mentioned  by  Watson,  men  per- 
fectly sober  have  been  arrested  in  the  streets  during  very  cold 
weather  for  being  drunk,  when  the  cause  of  their  strange  beha- 
vior was  traced  to  the  effects  of  the  extreme  cold. 

9.  Insolation,  sudden  arrest  of  hemorrhoidal  or  menstrual  dis- 
charges, night  vigils,  excessive  indulgence  in  the  pleasures  of  the 
table,  and  position  (as  may  be  instanced  in  a  tribe  of  South  Amer- 
ican Indians  who  stand  upon  their  heads  some  time  prior  to  under- 
taking a  long  journey,  which  they  assert  prevents  subsequent 
fatigue  and  exhaustion),  are  all  prolific  sources  of  dangerous  at- 
tacks of  active  cerebral  congestion.  Spitzka  says,  "  The  suppres- 
sion of  habitual  discharges,  of  the  hemorrhoidal  flux,  and  the 
cessation  of  menstruation,  are  associated  in  many  instances  with 
the  more  formidable  grade  of  cerebral  hypersemia.  Many  phe- 
nomena of  so-called  climacteric  insanity  depend  on  congestive 
states.  The  sudden  closure  of  an  old  ulcer  or  the  removal  of 
hemorrhoids  in  advanced  life  has  in  some  well-established  instances 
provoked  alarming  seizures  not  unlike  those  noted  with  paretic 
dementia.  The  chain  of  proof  establishing  the  direct  influence 
of  physiological  and  pathological  discharges  on  the  vascular  con- 
trolling apparatus  of  the  brain  is  most  complete.  Not  alone 
cumulative  clinical  observation,  but  the  occasional  happier  result 
of  therapeutical  procedures  based  on  this  supposed  interdependence, 
supports  it.  Thus,  the  congestive  cerebral  state  is  recovered  from 
when  the  ruenstrual  or  hemorrhoidal  flow  is  re-established,  or  an 
issue  is  formed  in  the  nape  of  the  neck,  or  an  old  ulcer  is  allowed 
to  reopen." 

In  corroboration  of  this,  I  had  occasion  to  observe  many  years 
ago,  at  the  St.  Louis  City  Hospital,  the  case  of  a  woman  who 
while  menstruating  had  scrubbed  a  pavement  on  a  cold  day  with 
bare  feet ;  the  discharge  was  immediately  suppressed,  and  she 
died  on  the  fourth  day,  from  the  effects  of  the  most  intense  cere- 
bral hyperEemia  that  I  ever  witnessed. 

After  commenting  upon  this  subject  as  above  quoted,  Spitzka,  in 
a  highly  important  foot-note,  observes,  "  The  treatment  of  paretic 


36  DISEASES    OF    THE    NERVOUS   SYSTEM. 

dementia,  particularly  of  the  congestive  type,  is  also  based  on 
this  relation.  The  irritating  antimonial  ointment  and  issues  in 
the  nape  of  the  neck,  etc.,  have  been  lauded  by  older  observers, 
and  in  two  of  my  own  cases  have  had  the  best  results, — in  one, 
indeed,  with  established  restitutio  ad  integrum  of  now  nearly  two 
years'  duration.  I  am  inclined  to  suppose  that  its  abandonment 
is  due  to  an  improper  selection  of  cases.  In  the  ordinary  prema- 
ture senility  and  syphilitic  types  such  treatment  is  altogether  in- 
effective. It  is  applicable  but  to  a  minority  of  cases  at  best,  and 
to  them  only  at  an  early  period.  It  is  probably  to  a  similar  form 
of  congestion  that  Bouchut  refers  when  ('  Les  Nevroses  conges- 
tives  de  I'Encephale,'  Gazette  des  Hopitaux,  1869)  he  speaks  of  a 
cerebral  hypersemia  developing  under  the  mask  of  a  meningitis, — 
an  expression  that  may  be  allowed  if  understood  in  the  same  sense 
as  the  comparison  between  hydrocejjhaloid  and  hydrocephalus."* 
Speaking  of  the  "  neural  irritability"  from  cerebral  hypersemia 
of  professional  men  suffering  from  worry  incident  to  professional 
life  and  irregular  living,  so  provocative  of  gastric  disturbances, 
with  resulting  insomnia  and  constipation,  Spitzka  makes  the  fol- 
lowing statements  :  "  In  such  a  case  the  insomnia,  usually  due  to 
neural  irritability,  if  not  aggravated  by  an  existing  dyspepsia,  leads 
to  such  a  one,  and  a  circulus  vitiosus  familiar  to  all  physicians  is 
established.  Each  of  the  factors  concerned  involves  strain  of  the 
cerebral  vaso-motor  apparatus,  but  none  more  so  than  insomnia. 
It  is  not  so  much  the  intensity  of  the  strain  as  its  long  duration, 
and  the  exhaustion  of  the  centre  which  in  sleep  is  supposed  to  be 
at  comparative  rest.  This  rest  is  not  obtained,  and,  in  conformity 
to  the  laws  of  neural  exhaustion,  that  centre  becomes  morbidly 
irritable.  Now,  gastric  irritation  is  competent  to  produce  a  reflex 
influence  on  even  the  healthy  cerebral  organ  ;  to  do  so  it  must  be 
a  severe  one ;  but  with  the  class  of  persons  alluded  to  the  slightest 
indiscretion  in  food  or  drink  is  sufficient  to  set  up  reflex  vertigo 
or  headache.  The  current  theory  regarding  these  symptoms  is 
that  they  are  due  to  stimulation  of  the  vaso-constrictors  and  en- 
suing cerebral  anaemia ;  but  the  subjects  before  us  will  usually  be 
found  to  flush  up  instead  of  becoming  pale,  as  in  simple  vertigo 


*  Spitzka,  article  on  "  Anaemia  and  Hypersemia  of  the  Brain  and  Spinal 
Cord,"  in  Pepper's  System  of  Medicine,  vol.  v.,  1886. 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  37 

a  stomacho  Iseso,  or,  if  there  be  initial  paleness,  there  is  a  second- 
ary flush,  as  if  the  tired  arterial  muscle  had  become  exhausted 
by  the  eifort  at  obeying  the  reflex  stimulus.  In  addition,  a  pro- 
fuse perspiration  sometimes  breaks  out  on  the  upper  part  of  the 
body." 

We  must  confess  that  this  distinction  of  our  learned  author 
between  the  action  of  the  vaso-constrictors  in  these  cases  and  the 
mechanism  of  vertigo  a  stomacho  l£eso,  so  graphically  described 
by  Trous33au,  seems  rather  too  subtle  for  general  appreciation. 

10.  Atrophy  of  the  brain  is  still  another  source  of  hypertemia. 
Atrophy  of  the  brain  itself  may  occur  in  many  ways ;  but  when 
it  exists,  and  a  portion  of  the  brain  has  wasted  away,  a  vacuum 
forms, — or  rather  would  form,  were  it  not  that,  in  consequence 
of  a  compensatory  vascular  dilatation,  the  wasted  brain  is  replaced 
by  blood ;  and  thus  we  have  here  also  another  cause  of  imdue 
determination  of  blood  to  that  organ. 

11.  One  more  cause  of  hypersemia,  the  result  of  a  diversity 
of  influences,  is  yet  to  be  enumerated.  I  refer  to  paralysis  of 
the  vaso-motor  nerves,  accomplished  in  many  different  ways,  prom- 
inent among  which  are :  section  of  certain  nerves,  emotions,  ex- 
cessive intellectual  labor,  narcotic  poisons,  and,  very  frequently, 
abuse  of  alcoholic  stimulants.  In  order  fully  to  understand  the 
manner  in  which  paralysis  of  the  vaso-motor  nerves  causes  hy- 
persemia,  we  must  first  consider  the  functions  of  these  nerves,  the 
neuro-physiology  of  the  vessels  to  which  they  are  distributed,  and 
the  presiding  influence  exerted  by  these  nerves  over  their  proper  in- 
nervation. The  blood-vessels  are  furnished  with  a  certain  elastic 
coat,  which,  by  alternate  expansion  and  contraction,  regulates  the 
flow,  and  consequently  the  supply,  of  blood  to  certain  parts.  As 
the  stimulus  to  the  organs  of  the  body  is  derived  from  nervous/  / 
centres,  and  conducted  by  nerves,  it  follows  that  this  contractile 
coat  must  also  be  supplied  by  a  nerve,  which  in  this  case  is 
derived  from  the  great  sympathetic,  from  which  all  vaso-motor 
nerves  emanate. 

The  nerves  subserving  this  function  are  called  the  vaso-motor, 
— in  other  words,  nerves  regulating  the  movements  of  the  vessels. 
When  no  pernicious  influence  acts  upon  these  nerves,  they  perform 
their  functions  normally,  unless  the  coats  of  the  vessels  have 
undergone  some  change  of  structure  rendering  it  impossible  for 


38  DISEASES   OF   THE   NERVOUS   SYSTEM. 

them  to  respond  to  the  impulses  of  the  nerve-force.  But  where 
injurious  impressions  are  exerted,  they  seriously  interfere  with 
the  appropriate  action  of  the  nerve,  and  more  or  less  impede  or 
augment  the  circulation  When  a  vaso-motor  centre  or  its  nerve 
is  irritated,  the  arterioles  thereby  supplied  immediately  contract. 
But  when  a  paralysis  of  these  nerves  exists,  the  reverse  takes 
place :  the  nerves  lose  their  excitability  and  are  unable  to  trans- 
mit the  command  for  contraction,  the  arterioles  remain  as  a  con- 
sequence dilated,  and  hypersemia  results. 

It  has  already  been  observed  that  the  causes  of  such  a  paralysis 
are  various,  those  most  prevalent  being  such  poisons  as  opium 
and  other  narcotics.  Alcohol  is  the  most  common  source  of 
mischief  in  this  respect.  Excessive  intellectual  work  is  also 
mentioned  by  some  writers  as  a  prolific  and  disastrous  cause  of 
hypersemia. 

Having  heretofore  considered  the  different  causes  of  hypersemia 
of  an  active  character,  it  behooves  us  to  review  some  of  the  causes 
of  passive,  venous,  or  congestive  hypersemia. 

Passive  hypercemia,  or  congestive  hyjiercemia,  it  is  well  to  recol- 
lect, may  be  produced  by  strangulation,  pressure  on  venous  trunks, 
violent  expiratory  efforts  "  while  the  glottis  is  contracted,"  im- 
pediments to  the  functions  of  the  heart,  and  altered  or  pathologi- 
cal conditions  of  the  lungs. 

There  is  nothing  which  exercises  so  much  power  in  producing 
passive  hypersemia  of  the  brain  as  strangulation :  this  is  best  ex- 
emplified in  hanging,  where  congestion  immediately  takes  place. 
The  modus  operandi  is,  that  it  simply  opposes  or  prevents  the 
return  of  venous  blood  to  the  right  side  of  the  heart  by  a  mechan- 
ical obstacle.  Pressure  upon  venous  trunks  produces  results  iden- 
tical with  those  of  strangulation,  by  obstructing  the  return  of 
venous  blood  to  the  heart.  Tumors  in  the  neck  pressing  upon 
the  jugular  vein,  or  aneurism  in  the  thorax  j)ressing  upon  the 
vena  cava  descendens,  may  be  cited  as  causes  having  a  similar 
result.  The  violent  expiratory  efforts  previously  alluded  to  are 
often  witnessed  in  persons  playing  upon  wind-instruments  which 
require  the  forcible  expulsion  of  air  from  the  lungs.  Loud  and 
prolonged  singing  and  speaking,  the  straining  of  parturient 
women  and  of  persons  at  stool,  and  violent  muscular  exercise, 
may  also  be  classed  in  the  same  category  of  causes.     A  better 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  39 

illustration  is  afforded  by  the  rapid  succession  of  expiratory  acts 
in  whooping-cough. 

The  impediments  to  the  heart's  function  are  numerous^  and 
generally  productive  of  hypersemia  of  a  congestive  form.  Let  us 
suppose,  by  way  of  illustration,  that  we  have  a  case  of  disease  of 
the  aortic  valves,  accompanied  by  regurgitation.  How  will  this 
produce  hypersemia  ?  The  arterial  blood  has  not  perfect  exit  from 
the  left  ventricle  of  the  heart  during  the  systolic  contraction,  and 
hence  prevents  the  free  entrance  of  the  blood,  through  the  mitral 
valves,  returning  from  the  lungs ;  the  natural  result  is  that  the 
arterial  blood,  being  unduly  retained  in  the  lungs,  obstructs  the 
venous  blood  flowing  from  the  right  ventricle,  the  obstruction  in 
the  right  ventricle  is  soon  appreciated  by  the  right  auricle,  and 
finally,  the  free  entrance  of  blood  from  the  vena  cava  descendens 
being  obstructed,  we  will  have  passive  congestion  of  the  brain. 
There  is  in  nature,  however,  a  grand  force  which  exerts  itself 
whenever  occasion  demands, — the  principle  of  compensation.  In 
obedience  to  this  salutary  law,  one  organ  being  diseased,,  another 
performs  double  labor,  or  one  part  of  an  organ  being  injured  in  any 
way,  the  healthy  portion  makes  up  for  the  deficiency  by  increased 
action.  These  compensations  will  necessitate  an  hypertrophy, 
which  generally  occurs,  especially  in  cardiac  lesions  of  a  valvular 
nature.  The  left  ventricle  hypertrophies  and  performs  increased 
duty,  expelling  the  blood  from  its  cavity  with  augmented  force. 
When  the  compensatory  action  is  sufficient,  there  will  be  no  con- 
gestive hypersemia  resulting. 

The  last  cause  we  have  to  consider  is  the  alteration  in  the 
physiological  functions  in  the  lungs,  with  or  without  change  of 
structure,  resulting  in  simple  capillary  obstruction.  In  hydro- 
thorax  there  is  a  liquid  effusion,  and  in  emphysema  a  larger  vol- 
ume of  air  presses  upon  the  capillaries,  obstructs  the  pulmonary 
circulation,  and  impedes  the  flow  of  blood  from  the  right  ventricle 
through  the  branches  of  the  pulmonary  artery.  The  right  auricle 
becomes  engorged  with  blood,  a  large  column  of  which  fills  the 
jugular  veins,  engendering  passive  hypersemia  of  the  brain.  It 
must  be  observed  that  in  both  these  cases  nature  often  endeavors 
to  compensate  for  the  lack  of  power  of  the  right  ventricle  to 
propel  the  blood  through  the  obstructed  capillaries,  by  effecting 
hypertrophic  changes  in  its  walls. 


40 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


X 


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f 


Anatomical  Appearances. — It  is  not  always  easy  to  determine, 
upon  autopsy,  the  previous  existence  of  hypersemia.  The  amount 
of  blood  in  the  brain  after  death  corresponds  to  a  great  extent  to 
the  conditions  previously  existing.  The  effects  of  passive  hyper- 
semia are  quite  different  from  those  of  active  hypersemia,  and  not 
very  liable  to  be  confounded  with  them.  In  active  hypercemia 
some  of  the  principal  results  are  great  vascularity  of  the  affected 
parts,  numerous  puncta  vasculosa,  and  the  exudation  of  serum, 
occasioning  oedematous  infiltration,  especially  of  the  pia  and  in 
the  cerebral  tissue.  In  passive  hypercemia  (congestive)  we  may 
find  the  brain  hypersemic,  with  a  venous  plethora,  at  the  expense 
of  an  arterial  ansemia;  in  chronic  congestions,  I'etat  crible  of 
Duraud-Fardel.  However,  none  of  the  conditions  above  de- 
scribed are  conclusive  of  the  cause,  which  may  depend  upon  many 
different  circumstances,  and  indeed  it  may  be  said,  with  Gowers, 
that  "there  is  scarcely  any  pathological  anatomy  of  congestion 
of  the  brain.  Simple  active  congestion  disappears  after  death  in 
every  organ."  Indeed,  in  post-mortem  examinations,  incorrect 
deductions  as  to  the  existence  of  hypersemia  are  very  apt  to  be 
made,  the  arteries  at  the  base  of  the  brain  being  naturally  large, 
and  oftentimes  their  post-mortem  fulness  is  undoubtedly  influ- 
enced by  the  tendency  on  the  part  of  the  blood  to  gravitate  to 
more  dependent  parts.  The  distended  and  tortuous  blood-vessels 
on  the  top  of  the  brain  are  venous,  and  quite  capacious.  These 
vessels  are  almost  always  found  empty  after  a  long-continued  and 
exhausting  disease.  The  vessels  outside  of  the  brain,  therefore, 
afford  no  definite  evidence  of  hypersemia,  nor  does  the  presence 
of  a  large  or  a  small  quantity  of  blood  in  the  substance  always 
give  us  any  positive  information  on  which  to  build  our  conclu- 
sions for  the  supposed  presence  of  ante-mortem  congestion. 

The  brain-substance  receives  blood  from  capillaries  proceeding 
from  the  pia  mater,  and  the  vessels  of  the  cerebral  substance 
proper  are  too  minute  to  be  seen  by  the  naked  eye.  We  can,  it 
is  true,  judge  of  the  quantity  of  blood  these  capillaries  contain, 
approximately,  by  making  a  transverse  section  of  the  brain, 
causing  them  to  become  apparent  to  us  as  little  dots,  called  the 
puncta  vasculosa.  But  even  these  are  not  thoroughly  significant, 
for  the  rapidity  or  freedom  with  Avhich  the  blood  exudes  from 
them  is  often  due  to  change  in  its  constitution.     When  the  blood 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  41 

runs  slowly,  it  is  often  due  to  a  state  of  hyperinosis ;  when  freely, 
it  is  often  owing  to  a  deficiency  of  fibrin  in  it  (increased  fluidity), 
AS'liich  frequently  happens  in  cases  of  dyscrasia.  Here,  once  more, 
we  have  no  infallible  test  for  determining  the  presence  or  absence 
of  hypersemia.  The  knowdedge  of  the  effects  of  hyperaemia  willi  / 
undoubtedly  throw  much  light  upon  our  investigations,  and  enable  ? 
us  to  recognize  many  pathological  conditions  which  would  othe^-/ 
wise  escape  our  observation. 

In  cases  of  active  congestion,  the  capillaries  are  distended,  the 
blood  moves  very  slowly  through  them,  and  perhaps  also,  in  con- 
sequence of  some  cause  exercising  a  constantly-increasing  tension 
on  the  coats  of  the  vessels,  there  is  developed  upon  the  part  of 
the  capillaries  a  proneness  to  ti'ansude  serum  into  the  perivascular 
spaces  and  the  pia,  and  into  the  cerebral  substance ;  likewise  into 
the  ventricles  and  subarachnoidean  spaces  in  chronic  congestions. 
When  the  congestion  continues  for  some  time,  this  last  result  is 
undoubtedly  the  danger  to  be  feared. 

Serous  transudation  is  known  as 

COLLATERAL    (EDEMA. 

It  is  evident  that  the  collateral  oedema  cannot  distend  the  mem- 
branes, though  it  nevertheless  exerts  a  constant  pressure.  Does  it 
compress  the  brain  ?  Of  course  not.  The  fact  of  the  brain's  in- 
compressibility  has  already  been  established.  What,  then,  sustains 
the  constraining  impulse  ?  It  compresses  the  capillaries,  the  very 
vessels  whence  it  originated.  These  vessels  being  the  only  elastic 
portion  of  the  brain,  and  having  the  pressure  of  the  collateral 
oedema  exercised  upon  them,  their  calibre  is  diminished  or  entirely 
obstructed  in  some  instances,  and  an  ansemia  is  the  result.  In 
other  words,  the  parent  vessels  are  strangulated  by  their  own 
progeny,  the  collateral  oedema.  You  must  not  suppose,  how- 
ever, that  collateral  oedema  necessarily  occurs  in  all  cases  of  con- 
gestion. Its  amount  is  proportional  to  the  intensity  of  the  con- 
gestion. In  death  from  congestive  hyperaemia,  therefore,  we 
generally  find  the  affected  districts  more  or  less  anaemic. 

Gowers,  referring  to  passive  congestion,  says,  "  It  is  probable, 
however,  that  the  spaces  around  the  vessels,  which  arise  by  a  dila- 
tation of  the  perivascular  sheaths,  are  increased  by  mechanical 
congestion,  although  here  again,  apart  from  congestion,  the  varia- 


42  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tions  met  with  are  so  great,  and  the  size  of  these  spaces  is  often 
so  considerable,  that  the  influence  of  congestion  upon  them  cannot 
be  regarded  as  proved.  Even  in  young  persons  their  size  is  often 
considerable.  .  .  . 

"Bulgings  of  the  capillaries  have  been  occasionally  seen. 
After  aspliyxial  modes  of  death  it  is  common  to  find  that  vessels 
here  and  there  have  given  way,  so  that  the  lymphatic  sheath  is 
filled  with  blood.  Blood-pigment  in  the  sheaths  has  been  found 
in  cases  of  slighter  long-continued  congestion  (Bastian).  Lastly, 
minute  microscopic  hemorrhages  into  the  cerebral  substance  may 
be  found  almost  constantly  in  these  cases.  .  .  . 

"  While  the  pathological  anatomy  of  congestion  is  thus  to  a 
considerable  extent  negative,  it  is  important  to  point  out  that  this 
affords  no  reason  for  doubting  the  occurrence  of  the  condition,  since 
on  other  parts  conspicuous  congestion  during  life  may  leave  no 
tracej'^ 

The  child's  brain  is  more  vascular  than  that  of  the  adult  or 
of  the  old  man. 

Some  portions  of  the  brain  are  much  more  vascular  than  others  : 
they  may  be  classified  as  to  their  vascularity  as  follows.  In  the 
first  place,  the  gray  substance  contains  more  vessels  than  the 
white ;  the  corpora  striata  contain  a  great  number  of  small  ves- 
sels in  their  cortical  zone ;  the  optic  thalami  are  next  in  order ; 
then  the  corpus  callosum  ;  then  the  cerebellum,  which  is  particu- 
larly vascular  in  its  peripheral  part  about  the  level  of  the  corpora 
dentata.  Sections  of  the  pons  present  only  a  small  number  of 
vascular  points. 

Other  facts  should  be  remembered  when  making  post-mortem 
examinations. 

Ante-mortem  congestion  may  be  effaced  after  death.  It  is 
necessary  to  determine  in  such  cases  whether  the  cerebral  tissues 
and  the  ventricles  have  undergone  any  modifications  which  follow 
in  the  train  of  ordinary  congestion. 

Localization  of  results  in  such  cases  has  its  influence,  because 
dorsal  decubitus  will  often  show  congestion  in  the  occipital 
region,  as  the  result  of  a  post-mortem  and  not  of  an  ante-mortem 
condition. 

*  Italics  my  o-wn. 


GENERAL   HYPERJ^^MIA   OF   THE   BRAIN.  45 

Cadaveric  congestions  and  tliose  associated  with  the  agony  of 
death  are  limited  to  the  membranes  of  the  brain  and  its  surface, 
whereas  pathological  cerebral  hypersemia  penetrates  into  the 
cerebral  substance  and  ventricles. 

Cerebral  congestion  is  not  always  equally  marked  or  limited 
over  the  entire  extent  of  the  brain ;  ordinarily  occupying  both 
the  white  and  the  gray  substance,  it  may  predominate  in  one  more 
than  in  the  other. 

The  membranes  are  never  adherent  to  the  cerebral  pulp  in 
congestion  of  the  brain. 

Retinal  cong-estion  during;  life  is  often  associated  with  cerebral 
hyperssmia. 

Collateral  oedema  is  accompanied  by  whiteness  of  the  brain- 
substance,  which  is  moist  and  shining. 

The  development  of  Pacchionian  bodies  is  not  a  necessary 
concomitant  of  cerebral  congestion. 

SYMPTOMS. 

By  many  authorities  brain-symptoms  are  divided  into  symp- 
toms of  irritation  and  symptoms  of  depression :  the  former  are 
due  to  increased  excitability,  the  latter  to  diminished  excitability 
of  the  brain.  There  is  no  absolute  order  of  their  development : 
those  of  irritation  usually  precede  those  of  depression ;  sometimes 
they  blend  together  from  the  very  beginning;  at  other  times, 
though  rarely,  the  latter  are  the  only  ones  manifest  from  the 
onset. 

Niemeyer,  who  has  given  the  most  satisfactory  explanation  of 
the  philosophy  of  these  conditions,  states,  with  respect  to  the 
symptoms  of  irritation,  that  "experience  shows  that  nerves 
passing  through  bony  canals  in  company  with  blood-vessels  are 
thrown  into  a  state  of  increased  excitability  and  morbid  excite- 
ment by  overfilling  of  these  vessels ;  the  nerve-elements  of  the 
brain,  enclosed  by  the  dura  mater  and  skull,  are  in  a  like  condi- 
tion when  the  cerebral  vessels  are  overfilled." 

Brain-pressure,  therefore,  is  of  some  significance  in  the  expla- 
nation of  the  former  condition,  but  not  in  that  of  the  symptoms 
of  depression  or  paralysis. 

The  latter — namely,  the  symptoms  of  depression  in  congestive 
hypersemia — are  explained  by  the  failure  of  the  venous  blood 


44  DISEASES   OF   THE   NERVOUS   SYSTEM. 

to  escape  freely  from  the  brain,  whereby  the  entrance  of  fresh 
arterial  blood  into  the  capillaries  is  prevented.  The  absence  of 
oxygenated  blood,  therefore,  plays  a  most  important  part  under 
these  circumstances. 

"  It  is  for  this  reason,"  continues  Niemeyer,  "  that  the  symp- 
toms of  cerebral  hypersemia  are  very  similar  to  or  exactly  iden- 
tical with  those  of  cerebral  anaemia;  this  is  true  in  regard  to 
congestive  hypersemia  and  anaemia,  and  the  explanation  of  the 
correspondence  is  easy.  In  both  cases  the  brain  lacks  its  new 
supply  of  arterial  blood.". 

The  symptoms  of  depression  in  acute  fluxionary  hypersemia  are 
even  more  readily  explained  by  the  last-mentioned  author,  upon 
the  hypothesis  that  the  collateral  oedema  of  the  brain  results  in 
"  capillary  anaemia,  a  condition  directly  opposite  to  the  original 
hypersemia ;"  in  consequence  of  which,  the  arterialized  oxygenated 
blood,  if  present  at  all,  is  greatly  diminished  in  quantity. 

Before  studying  the  symptomatology  proper  of  cerebral  hyper- 
semia, I  would  remark  that  the  development  of  brain-symptoms 
in  fever  is  not  the  result  solely  of  cerebral  congestion,  but  is  to 
a  great  extent  induced  by  the  increased  temperature  of  the  blood 
and  the  consequent  augmented  tissue-metamorphosis  and  other 
states  of  the  fluids  essentially  characteristic  of  fever. 

Therapeutically  this  is  a  fact  of  vital  importance,  and  it  is  for 
this  reason  that  Graves,  of  Dublin,  immortalized  himself  "by 
feeding  and  not  starving  fevers ;"  appreciating  the  absurdity 
of  combating  delirium  and  other  brain-symptoms  in  these  cases 
upon  the  pathological  basis  of  congestion,  which  does  not  neces- 
sarily exist. 

The  symptoms  of  irritation  and  of  depression  under  varying 
circumstances  and  conditions  appear  in  the  sensory,  motor,  and  psy- 
chical domains,  sometimes  blending  and  sometimes  predominating 
in  one  more  than  in  the  other. 

Convulsions  and  delirium  are  typical  symptoms  of  irritation ; 
paralysis  and  coma  are  typical  symptoms  of  depression. 

There  are  three  forms  of  hypersemia, — the  mild,  the  severe,  and 
the  apoplectic.  A  few  symptoms  are  common  to  all  forms  of 
hypersemia. 

Hammond  adds  other  forms  to  this  classification, — viz.,  the 
"paralytic,  convulsive,  soporific,  maniacal,  and  aphonic." 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  45 

SYMPTOMS   OF  THE   MILD   FORM. 

1.  Increased  excitability  and  general  hyperesthesia  of  the 
nerves  of  special  sense. 

2.  Contraction  of  the  pupils. 

3.  Insomnia,  or  vivid  and  frightful  dreams. 

4.  Vomiting  (spontaneous). 

5.  Flushing  of  the  face.  This  symptom,  however,  is  some- 
times absent. 

In  tliis  connection  it  should  not  be  forgotten  that  great  pallor 
of  the  countenance  sometimes  accompanies  the  most  dangerous 
forms  of  hypersemia. 

6.  Constipation,  accompanied  with  a  very  torpid  condition  of 
the  bowels. 

7.  Diifused  headache,  sometimes  very  violent. 

The  headache  is  at  times  lancinating  and  increased  by  move- 
ments, noises,  heat,  and  light,  making  all  intellectual  efforts  very 
painful,  if  not  impossible.    (Jaccoud.) 

8.  A  constant  buzzing  in  the  ears  (tinnitus  aurium). 

9.  Dizziness  in  proportion  to  the  severity  of  the  attacks. 

The  cerebral  form  of  vertigo  is  objective  in  character ;  sur- 
rounding objects  move,  not  the  patient  himself;  closing  the  eyes 
relieves  it,  and  does  not  relieve  sympathetic  disturbances.  (Da 
Costa.) 

"NYhen  diseases  of  the  posterior  cranial  fossae  are  described, 
special  distinctions  as  to  the  character  of  vertigo  will  be  made. 
(See  termination  of  lecture  on  Partial  Cerebral  Ansemia.) 

10.  Motor  and  sensory  symptoms  of  excitation,  and  later  on 
of  depression,  more  or  less  marked. 

11.  Light  and  noises  are  badly  tolerated. 

12.  More  or  less  psychical  disturbance. 

13.  Vomiting,  which  when  protracted  is  frequently  accompa- 
nied with  a  slow  pulse. 

14.  Sensations  of  heat  and  pulsations  in  the  head,  with  violent 
beating  of  the  carotids. 

15.  The  conjunctivse  are  often,  but  not  always,  injected. 

The  symptoms  of  the  mild  stage  of  cerebral  congestion  may 
frequently  return  when  the  causes  for  their  excitation  are  repeated. 
They  may  last  from  a  few  hours  to  several  days. 


46  DISEASES   OF   THE   NERVOUS   SYSTEM. 


SEVERE   FORM   OF   CEREBRAL   CONGESTION. 

In  the  severe  form,  characterized  by  great  intellectual  excite- 
ment and  disorder,  nearly  all  of  the  above  symptoms  present 
themselves,  increased  in  intensity  and  accompanied  by  delirium, 
hallucinations,  illusions,  and  delusions.  Simple  delirium  is  a 
wandering  of  the  mind,  often  attended  by  fever,  of  which  it  may 
be  the  result.  It  is  not  a  symptom,  necessarily,  of  hyperaemia, 
as  fever  is  absent  in  the  latter,  but  rather  points  to  blood-poison- 
ing or  excessive  tissue-oxidation,  accompanied  by  increased  eleva- 
tion of  temperature. 

A  man  is  in  a  certain  sense  insane  when  he  is  unable  to  use 
his  mental  powers  to  dispel  hallucinations  which  are  nothing 
but  imaginations  of  things  having  no  real  existence  outside  of 
the  patient's  brain ;  he  then  labors  under  a  delusion.  If  he  im- 
agines animals  not  actually  present  jumping  upon  his  bed,  he 
labors  under  an  hallucination  ;  while  if  he  perverts  the  impression 
received  in  his  brain  through  the  senses  from  external  objects 
having  a  real  material  basis  of  existence, — as,  for  instance,  if  he 
imagines  a  chair  really  present  to  be  a  living,  moving  object, 
approaching  or  threatening, — he  then  has  illusions. 

Delirium  tremens  should  never  be  confounded  Avith  ordinary 
hypersemic  delirium,  from  the  easily-recognized  fact  of  the  invol- 
untary tremor,  coinciding  with  "  the  characteristic  good-natured 
and  loquacious  delirium"  almost  pathognomonic  of  the  former. 

In  the  grave  form,  sensorial  disorders  are  the  first  phenomena 
to  manifest  themselves,  accompanied  with  illusions  and  hallucina- 
tions. In  other  more  serious  forms  of  this  variety  of  cerebral 
hyperoemia,  delusions  and  other  psychical  disturbances  are  promi- 
nent, the  latter  originating  directly,  and  not  through  sensorial 
perversions.  Muscular  agitations  and  distorted  impulses  often 
appear,  the  patient  at  times  becoming  very  violent. 

If  the  condition  is  not  soon  relieved,  all  the  symptoms  become 
aggravated,  the  pulse  increases  in  frequency  and  diminishes  in 
volume,  the  skin  becomes  cold  and  clammy,  but  the  patient  has 
no  fever. 

With  increased  muscular  agitation  and  general  relaxation, 
accompanied  with  involuntary  evacuations,  the  respiration  soon 
becomes  stertorous,  and  stupor  and  coma  close  the  scene. 


GENERAL   HYPEREMIA    OF   THE   BRAIN.  47 

Paralysis  preceding  this  condition  is  rare,  and,  if  present,  is 
generally  circumscribed. 

In  old  men  the  sudden  development  of  delirium  at  night  is 
the  first  and  only  symptom  of  this  form.  It  is  nocturnally 
recurrent,  and  is  but  too  frequently  followed  by  a  fatal  coma. 

Durand-Fardel  has  noticed,  as  a  frequent  accompaniment  of 
the  senile  form  of  grave  cerebral  hyperemia,  "  an  abundant  sero- 
mucous  secretion  of  the  conjunctiva  and  of  the  buccal  mucous 
membrane." 

APOPLECTIC   FORM. 

The  apoplectic  form  is  characterized  by  a  sudden  abolition 
of  consciousness,  sensation,  and  voluntary  motion.  The  indi- 
vidual suddenly  falls,  in  a  condition  of  perfect  relaxation  and 
prostration. 

The  reflexes  are  preserved ;  the  insensibility  is  profound,  and 
involuntary  evacuations  occur. 

Consciousness  may  be  gradually  restored  after  a  few  hours  or 
days. 

Sometimes  a  temporary  paralysis,  lasting  but  a  very  short  time, 
follows  the  more  purely  apoplectic  phenomena. 

In  rare  instances  a  hemiplegia  is  observed,  to  explain  which 
nothing  can  be  detected  at  the  autopsy  but  a  diffused  cerebral 
congestion.  "Some  facts  show  the  possibility  of  a  hemiplegic 
form  of  paralysis ;  the  autopsy  sometimes  demonstrates  a  reason 
for  the  existence  of  this  symptom  in  revealing  a  congestion  pre- 
dominating upon  the  side  of  the  brain  opposite  to  the  paralysis 
(Dechambre) ;  but  it  sometimes  happens  that  the  congestion  is 
found  equally  diffused  in  both  hemispheres,  and  the  most  minute 
examination  is  incapable  of  explaining  the  unilateral  seat  of  the 
phenomena."    (Grisolle). 

Jaccoud,  commenting  upon  this  subject,  remarks,  "  Taking  it 
for  granted  that  cadaveric  investigations  in  this  respect  are  com- 
plete, it  is  necessary  in  interpreting  these  obscure  facts  to  recur  to 
one  or  the  other  of  the  following  hypotheses :  congestion  being 
admitted  as  being  equally  diffused  in  both  hemispheres  after  death, 
it  certainly  was  not  in  the  beginning ;  the  sanguineous  afflux 
produced  in  one  portion  of  the  brain  an  oedematous  infiltration 
more  considerable  in  one  part  than  in  the  other.  Whilst  all  this 
is  undoubtedly  obscure,  one  fact  is  certain  and  deserves  to  be  re- 


48  DISEASES   OF   THE   NERVOUS  SYSTEM. 

membered, — namelj,  a  possibility  of  unilateral  symptoms  (namely, 
a  paralysis  or  convulsions)  with  a  generalized  cerebral  congestion, 
without  hemorrhage." 

The  word  apoplexy  is  generally  used  to  express  the  effects  pro- 
duced by  an  extravasation  of  blood  into  the  cerebral  substance. 
By  the  apoplectic  form  of  h^^ersemia,  however,  is  meant  that 
variety  the  effects  of  which  are  somewhat  similar,  so  far  as  symp- 
toms go,  to  those  of  apoplectic  extravasation.  The  main  symptoms 
of  this  form  are  sudden  loss  of  consciousness,  and  abolition  of 
sensation  and  voluntary  motion  (the  ictus  sanguinis  of  the  old 
WTiters). 

The  different  symptoms  enumerated  as  belonging  to  the  several 
forms  of  hypersemia  of  the  brain  are  also  common  to  other  affec- 
tions, and  it  is  essential  to  be  able  to  discriminate  between  them, 
iu  order  not  to  adopt  a  treatment  based  upon  an  incorrect  diag- 
nosis, which  in  certain  instances  might  prove  dangerous,  or  even 
fatal ;  this  can  be  accomplished  only  by  a  careful  consideration  of 
all  extra-cranial  causes  of  h}"per£emia.  Were  we,  for  instance,  to 
treat  a  hypersemic  patient  for  ansemia,  we  should  be  likely  soon 
to  sign  his  burial  certificate,  though  the  pallor  sometimes  present 
in  hyperasmia  might  lead  us  to  think  that  the  patient  was  suffer- 
ing from  anaemia. 

It  happens  that  hypersemia  in  children  exhibits  very  severe 
symptoms  which  may  very  closely  resemble  those  of  meningitis. 
The  latter  disease  is  very  fatal,  while  the  former  is  not  neces- 
sarily so :  it  therefore  behooves  us  to  guard  against  the  error 
of  imagining  that  we  have  controlled  a  meningitis — ^which  really 
never  existed.  The  previous  history  will  throw  considerable  light 
upon  the  case,  and  greatly  aid  in  the  diagnosis.  If  the  child  has 
been  very  well  until  the  day  preceding  the  attack,  if  it  has  suf- 
fered from  no  contusion  about  the  head,  or  other  severe  injury,  we 
may  after  a  short  lapse  of  time  generally  give  a  favorable  prog- 
nosis, especially  if  the  convulsions  do  not  recur  with  frequency 
and  the  temperature  be  normal. 

DIAGNOSIS    OF    CEEEBEAL,    HYPEREMIA. 

The  symptoms  of  apoplexy  may  be  induced  by  blood-poisoning 
(uraemia),  which  we  must  not  confound  with  the  apoplectic  form 
of  cerebral  congestion.     Insolatio  (sun-stroke),  which  also  destroys 


GENERAL  HYPEREMIA   OF   THE   BRAIN.  49 

life  by  suspending  the  nervous  energy,  is  not  the  result  of  hyper- 
semia,  but,  it  is  generally  conceded,  can  be  traced  to  an  elevation 
of  the  temperature  of  the  whole  body  so  high  as  to  be  incompat- 
ible with  the  functions  of  life,  and  fatal  to  the  proper  performance 
of  the  duties  of  the  nerve-centres. 

Stomachic  vertigo  presents  symptoms  congestive  in  character, 
but  we  should  remember  that  it  is  never  accompanied  by  loss 
of  consciousness,  and  the  symptoms  disappear  generally  after  the 
action  of  antidyspeptics  to  remove  the  cause. 

In  congestion  the  temperature  is  not  elevated,  which  makes  it 
easy  to  determine  whether  or  not  the  symptoms  be  due  to  fever. 
All  we  have  to  do  is  to  place  the  thermometer  in  the  axilla,  and 
the  diagnosis  is  rendered  more  certain. 

The  symptoms  are  always  of  short  duration;  a  point  of  the 
greatest  importance  and  significance,  as  a  prolongation  of  the 
symptomatic  indications  would  cause  grave  suspicions  of  serious 
lesions,  or  of  meningitis. 

One  marked  characteristic  feature  of  the  symptoms  of  cerebral 
congestion  is,  that  they  are  general  and  diffused,  not  localized  or 
limited. 

In  congestion  the  breathing  is  regular,  not  stertorous,  and  the 
pulse  is  but  little  accelerated,  though  usually  quite  strong.  In 
syncope,  on  the  other  hand,  the  breathing  is  impeded,  the  pulse 
very  feeble  and  irregular,  and  the  face  remarkably  pale.  This  last 
fact  must  not  have  undue  importance  attached  to  it,  since  we 
know  that  in  hypersemia  of  the  most  dangerous  type  the  coun- 
tenance is  sometimes  cadaverous. 

Loss  of  consciousness  being  characteristic  of  cerebral  hemor- 
rhage, epilepsy,  and  other  comatose  conditions,  we  may  be  un- 
able to  determine  its  cause.  If  in  such  a  dilemma  we  wait  until 
the  ordinary  period  for  an  epileptic  fit  to  pass  off",  and  by  differen- 
tial diagnosis  exclude  other  apoplectic  states,  we  can  soon  discrim- 
inate between  the  presence  and  the  absence  of  congestion.  The 
phenomena  attending  apoplectic  hypersemia  are  transient ;  in  epi- 
lepsy they  last  but  a  few  minutes ;  and  in  apoplexy,  if  the  coma 
be  not  fatal,  they  may  last  for  some  days. 

An  epileptic  attack  is  often  accompanied  by  convulsions.  Im- 
mediately examine  the  tongue  of  the  patient :  you  will  frequently, 
though  not  always,  find  it  lacerated.     The  control  of  the  sphincter 

4 


50 


DISEASES   OF   THE   NERVOUS  SYSTEM. 


muscles,  in  this  convulsive  disease,  is  sometimes  lost,  and  you  may 
find  an  involuntary  discharge  of  fseces  and  urine. 

An  examination  of  the  abdomen  and  thorax  may  lead  to  the 
discovery  of  an  aneurism  or  other  tumor  pressing  upon  some  im- 
portant blood-vessel,  or  enable  us  to  detect  some  cardiac  or  pul- 
monary lesion  causing  determination  of  blood  to  the  head. 

SPITZKA'S   TABLE  OP   THE  DIFFERENTIAL  DIAGNOSIS  OF 
CEREBRAL  HYPEREMIA  AND   CEREBRAL  ANEMIA. 


In  Ceeebeal  Anemia. 

In  Ceeebeal  Hypee^mia. 

Pupils. 

Usually  dilated  and  mo- 

Usually small    or    me- 

bile. 

dium. 

Respiration. 

Often     interrupted     by 
sighing  or  by  a  deep 
breath,  even  when  at 
rest. 

Normal. 

Headache. 

Either  sharp  and   ago- 

If  localized,   accompa- 

nizing, and  then  in  a 

nied  by  a  subjective 

limited  area,  or  a  gen- 

and    objective      (al- 

eral dull  ache,  inten- 

ways ?)      feeling      of 

sified  in  the  temples 

heat ;  if   general,     is 

and  over    or    behind 

compared  to  a  burst- 

the eyes. 

ing  or  steady  pressure. 

Activity. 

There  is  lassitude. 

There  is  indisposition  to 
exertion,  yet  the  pa- 
tient is  restless. 

Temperament. 

Lethargic,  with    excep- 

Choleric,    with     excep- 

tions. 

tions. 

Intellect. 

Inability  to  exert. 

Rather  confusion  than 
inability  of. 

Sleep. 

Insomnia,     interrupted 

Insomnia,    with    great 

by  trance-like  condi- 

restlessness,       varie- 

tions, in  which  the  pa- 

gated by   unpleasant 

tient  is  comparatively 

and  confused  dreams. 

comfortable.    Dreams 

often  pleasant. 

Upright      position      of 

Aggravates       all       the 

Either    without     influ- 

bod}'^. 

symptoms. 

ence  or  beneficial. 

Recumtent  position   of 

Ameliorates. 

Aggravates. 

body   and   dependent 

position  of  head. 

Influence    of    acts    in- 

If any,  a   sharp  head- 

Aggravation. 

volving  deep  inspira- 

ache may  ensue,  but 

tion,  such  as  blowing, 

the    other    symptoms 

straining      at      stool, 

are  not  aggravated. 

sneezing,  etc. 

As  a  slight  evidence  of  the  facility  with  which  a  mistake  may 
be  made  in  the  diagnosis  and  prognosis  of  cerebral  hyperaemia,  I 
will  recall  a  case  of  more  than  usual  interest,  which  indelibly  im- 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  51 

pressed  upon  my  mind  the  necessity  for  caution  in  this  respect, 
A  very  distinguished  medical  man^  about  fifty  years  of  age,  whose 
life-long  habits  of  study  and  excessive  intellectual  labor  had 
brought  on  serious  brain-symptoms,  was  placed  under  my  charge. 
His  physicians,  who  were  eminent  practitioners,  had  diagnosti- 
cated cerebral  softening,  the  result  of  thrombosis.  Upon  exami- 
nation, the  patient  was  found  to  be  perfectly  incoherent ;  his  delu- 
sions were  marked  and  dangerous  in  character ;  his  countenance 
indicated  a  hebetude  amounting  almost  to  imbecility ;  aphasia  was 
a  prominent  symptom,  and  agraphia  very  pronouhced.  After  des- 
perate efforts  to  write,  he  folded  with  care  a  paper  on  which  were 
traced  a  few  illegible  hieroglyphics,  and,  placing  it  in  an  envelope 
with  no  address,  handed  it  to  me  with  a  request  that  I  should 
deliver  it  to  a  relative  whom  he  named.  Upon  my  calling  his 
attention  to  the  fact  that  the  name  and  address  had  been  omitted, 
he  became  quite  excited  and  irritated,  and  insisted  that  I  could  not 
read.  Amnesia  to  a  limited  extent  existed,  but  it  was  to  me  a 
fact  of  great  significance  that,  notwithstanding  his  utter  deficiency 
of  normal  ideation  and  the  presence  of  other  grave  and  alarming 
symptoms,  his  memory  of  the  past  and  his  interest  in  the  present 
were  far  from  being  greatly  impaired.  My  observation  and  ex- 
perience having  tended  to  make  me  believe  that  amnesia  and 
decided  apathy  are  the  ever-present,  concomitant,  and  charac- 
teristic symptoms  of  cerebral  softening,  I  made  a  particular  note 
of  their  partial  absence  in  this  case.  The  patient  also  presented 
some  sensory  and  motor  disturbances  :  he  was  partially  hemiplegic 
on  the  right  side,  and  the  orbicularis  oris  was  implicated,  as  was 
evinced  in  a  depression  of  the  right  labial  commissure,  which  per- 
mitted the  saliva  to  escape  and  dribble  down  his  face,  greatly 
adding  to  the  stolidity  of  his  appearance.  His  eyes  were  injected, 
and  his  emotional  faculties  were  preternaturally  mobile,  as  was 
made  apparent  by  his  alternate  attacks  of  weeping  and  laughing. 
I  was  made  conversant  with  the  fact  that  the  patient  had  for 
several  years  greatly  misused  narcotics  and  stimulants  while  seek- 
ing relief  from  terrible  attacks  of  neuralgia,  to  which  he  had 
been  a  victim  all  his  life.  This  indulgence,  as  usual,  was  due  to 
the  injudicious  advice  of  various  physicians.  Medical  men  are 
often  not  a  little  to  blame  for  the  moral,  physical,  and  intellectual 
wrecks  occasioned  by  their  countenancing  an  imprudent  resort  in 


52  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

their  patients  to  these  dangerous  and  potent  remedies  with  a  view 
of  relieving  temporary  pain.  They  seem  to  ignore  the  fire  they 
not  iafrequently  kindle,  by  the  creation  of  a  morbid  appetite  at 
times  so  difficult  to  restrain,  too  often,  alas  !  impossible  to  appease. 
The  patient  had  a  puffed,  bloated  appearance,  which  to  an  ex- 
perienced eye  strongly  indicated  the  familiar  evidences  of  chronic 
alcoholism.  His  mother  had  died  insane,  and  many  members  of 
his  family  were  distinguished  for  their  vagaries  and  eccentricities, 
probably  being  the  possessors  of  the  "  neurosis  spasmodica,"  living 
as  it  were  upon  the  border-land  of  insanity.  The  outlook  of  this 
case,  therefore,  was  certainly  dark ;  yet  upon  a  careful  investiga- 
tion and  analysis  of  all  the  symptoms,  and  particularly  laying 
stress  upon  the  history  of  the  disease,  which  was  that  of  alcohol- 
ism, I  diagnosticated  cerebral  congestion,  the  result  of  vaso-motor 
paralysis  induced  by  his  indiscretions,  for  which,  however,  I  be- 
lieve he  was  in  no  degree  morally  culpable.  Basing  the  treatment 
upon  the  conclusions  I  had  ventured  to  adopt,  I  gave  him  a 
preparation  containing  full  doses  of  Squibb's  fluid  extract  of  ergot, 
digitalis,  and  muriated  tincture  of  iron,  to  be  taken  three  or  four 
times  daily,  regulated  his  constipation  with  aloetic  laxatives,  ob- 
viated his  insomnia  with  bromide  of  potassium,  and  carefully 
made  him  eschew  all  malt,  vinous,  and  alcoholic  stimulants, 
together  with  his  favorite  narcotics. 

Had  the  diagnosis  of  his  previous  attendants  been  correct,  such 
a  therapeutic  course  would  have  been  unjustifiable,  not  to  say 
destructive.  I  had  the  gratification  to  see  him  rapidly  recover, 
and  in  two  weeks  nearly  all  his  symptoms  disappeared,  and  in 
two  months  he  was  discharged  cured.  The  hyperaemia  in  his 
case  was  doubtless  excessive,  and  the  resulting  collateral  oedema 
must  have  been  considerable,  and  a  nice  point  was  to  ascertain 
whether  the  presence  of  the  latter  in  the  delicate  brain-substance 
might  not  have  wrought  some  disastrous  structural  changes,  in 
which  case  the  damage  would  have  been  irretrievable  even  after 
the  cessation  or  disappearance  of  the  primary  congestion.  Such, 
however,  was  not  the  case,  the  patient's  restoration  being  com- 
plete. It  therefore  behooves  you,  gentlemen,  to  bear  in  recollec- 
tion and  appreciate  the  fact  that  without  a  proper  medical  history 
our  best  eflTorts  at  diag-nosis  will  oftentimes  be  rendered  futile. 


GENERAL   HYPEREMIA   OF   THE   BRAIN.  53 

PROGNOSIS   OF   HYPEREMIA. 

One  attack  of  hyperaemia  predisposes  to  another,  and  the  repe- 
tition of  such  attacks  may  result  in  atrophy,  softening,  or  other 
serious  lesion  of  the  brain,  due  to  the  profound  nutritive  de- 
rangement generated  by  the  dynamiG  influences  of  these  repeated 
fluxions. 

A  tendency  to  congestion  in  other  organs,  especially  the  lungs,  is 
a  contingency  not  infrequent,  and  one  which  we  should  anticipate. 

The  hyperaemia  induced  by  the  intemperate  use  of  alcohol  is 
sometimes  tenacious,  while  that  caused  by  anxiety  or  excessive 
mental  labor,  or  by  the  suppression  of  natural  discharges,  is 
generally  relieved  by  the  removal  of  the  cause. 

TREATMENT. 

Whenever  it  is  practicable,  the  first  step  in  the  inauguration  of 
a  successful  plan  of  treatment  is  to  ascertain  and  remove  the  cause 
of  the  congestion.  The  application  of  cold  to  the  head  is  most 
generally  advisable.  A  very  eligible  mode  of  applying  it  is  to 
introduce  pounded  ice  into  bladders  or  rubber  bags  and  lay  them 
on  the  patient's  head. 

Purgatives  constitute  most  efficient  therapeutic  measures,  pro- 
ducing marked  derivative  effects.  Among  the  many  that  can  be 
recommended,  a  combination  of  jalap  and  calomel  (about  ten  grains 
each)  deserves  special  notice. 

The  local  abstraction  of  blood  is  often  resoiied  to  beneficially 
in  cases  of  hyperaemia  resulting  from  suppression  of  certain  dis- 
charges, especially  menstrual  or  hemorrhoidal ;  if  the  former,  hot 
sitz-baths  are  also  useful.  The  bleeding  should  generally  be  done 
at  a  distance  from  the  brain,  by  the  application  of  leeches  to  the 
pituitary  membrane  or  the  margin  of  the  anus.  The  abstraction 
of  blood  from  the  general  circulation — i.e.,  by  venesection — is  un- 
doubtedly the  most  necessary  of  all  the  means  of  treating  certain 
varieties  of  congestion  of  the  brain,  due  to  intense  collateral 
h^^ersemia,  or  to  increased  pressure  in  the  carotids,  as  a  conse- 
quence of  obstructed  escape  of  blood  into  the  abdominal  aorta,  and, 
lastly,  in  very  threatening  cases,  where  it  would  be  dangerous  to 
await  the  action  of  milder  measures.  Venous  congestion,  with  few 
exceptions,  requires  bleeding  of  either  a  local  or  a  general  character. 


54  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Hypersemia  from  increased  cardiac  action,  uncomplicated  by  val- 
vular lesions,  with  undue  accumulation  of  blood  in  the  carotid 
arteries,  imperatively  demands  such  a  course.  In  aneurism  pro- 
ducing hypersemia,  or  in  cases  of  serious  collateral  oedema,  bleed- 
ing should  always  be  resorted  to,  keeping  in  mind  the  indications 
and  urgency  of  the  symptoms.  It  should  not  be  essayed  in  cases 
of  valvular  diseases  of  the  heart,  or  paralysis  of  the  vaso-motor 
nerves,  resulting  from  excessive  mental  efforts  or  from  narcotic  or 
alcoholic  indulgences.  These  latter  require  energetic  treatment 
without  bleeding,  and,  in  addition  to  the  methods  already  given, 
we  may  resort  to  warm  sinapisms.  This  last  method  may  often 
be  advantageously  employed,  the  irritating  effects  produced  by 
rubefacients  and  vesicants  causing  a  derivative  current  of  blood 
to  the  skin  and  other  parts.  TJbi  irritatio,  ibifluxus.  Therefore 
the  vesicants  and  irritants  are  most  advantageously  applied  to  the 
lower  extremities. 

We  should  not  overlook  the  important  fact  that  delirium  is 
increased  by  temperature.  The  reduction  of  the  temperature  is 
often  effectually  accomplished  by  the  judicious  use  of  quinine 
and  alcohol.  This  has  reference,  however,  to  delirium  produced  by 
fever,  and  not  to  that  of  congestion,  as  these  remedies  would,  in  the 
latter  complication,  prove  most  pernicious.  There  being  no  eleva- 
tion of  temperature,  you  have  simply  to  deal  with  the  mechanical 
effects  of  an  undue  determination  of  blood  to  the  parts. 

Ergot,  the  bromides,  and  digitalis  are  the  most  effectual  internal 
remedies  in  the  treatment  of  cerebral  hypersemia. 

Spitzka  says  that  "  ergot  of  rye,  with  its  preparations,  may  be 
regarded  as  the  cardinal  drug  in  cerebral  hypersemia.  There  are 
few  drugs  in  the  domain  of  neurological  therapeutics  which  are  so 
directly  antithetical  to  the  pathological  state  as  this  one.  There 
is  scarcely  a  case  of  cerebral  hypersemia  that  is  brought  to  the 
physician's  attention  but  may  be  regarded  as  being  in  part  due  to 
an  over-distention  of  the  cerebral  vascular  tubes.  This  is  directly 
overcome  by  ergot,  and  the  quantity  which  such  patients  will 
sometimes  bear  Mdthout  showing  signs  of  ergotism  is  something 
remarkable,  in  notable  contrast  with  the  subjects  of  cerebral 
anaemia,  who  are  usually  very  sensitive  to  it." 

The  thermo-cautery  is  often  useful,  applied  to  the  nucha  or 
over  painful  spots. 


GENERAL  HYPEREMIA   OF  THE   BRAHS".  55 

PARTIAL   HYPEREMIA. 

Partial  hypersemia  is  circumscribed  and  usually  limited  to  focal 
regions. 

In  other  words,  it  is  an  affection  which  disturbs  the  circulation 
over  distinctly-circumscribed  regions.  Niemeyer  states  that,  "  if 
an  artery  or  a  great  number  of  capillaries  be  compressed,  or 
otherwise  closed,  there  is  fluxion  in  the  collateral  branches ;  if, 
on  the  other  hand,  a  vein  be  contracted  or  closed,  there  is  a  con- 
gestion in  the  capillaries  supplying  it.  Of  course  there  will 
usually  be  fluxion  at  one  place,  congestion  at  another,  and  anaemia 
at  still  others,  at  the  same  time." 

Of  course  all  lesions  in  local  or  circumscribed  portions  of  the 
brain  or  of  one  particular  hemisphere,  such  as  tumors,  clots,  and 
foci  of  softening,  will  lead  to  partial  hypersemia. 

The  symptoms  of  the  latter  are  necessarily  more  localized  than 
those  of  general  diffused  cerebral  hypersemia. 

Hence  we  have  as  local  symptoms  the  so-called  "  Herdsymp- 
tome"  (Griesinger).  Among  these  are  "  circumscribed  headache, 
glimmering  or  sparks  before  one  eye,  or  blindness  of  one  eye, 
contraction  or  dilatation  of  one  pupil,  noise  or  deafness  in  one 
ear,  neuralgia  or  ansesthesia  limited  to  one  nerve,  but  especially 
spasms,  contractions,  or  paralysis  affecting  only  one  half  of  the 
body,  one  extremity,  or  a  single  group  of  muscles,  and,  lastly, 
partial  disturbance  of  the  mind." 

The  anatomical  appearances  are  just  as  difficult  to  discern  as 
those  of  general  cerebral  hj^ersemia. 

It  is  well  to  remember  that,  while  partial  hypersemia  produces 
certain  symptoms  directly,  it  is,  nevertheless,  a  fact  that  associated 
symptoms  exist,  superinduced  by  the  primary  hypersemia  and  the 
disturbances  of  the  circulation  consequent  thereupon. 

It  should,  moreover,  be  remembered  that  paralyses  which 
appear  and  disappear,  and  other  symptom  mutations,  can  be  ex- 
plained only  by  the  appearance  and  disappearance  of  collateral 
oedema  and  the  circulatory  disturbances  in  the  vicinity  of  tumors, 
abscesses,  clots,  softenings,  and  inflamjnatory  foci. 

In  speaking  of  excessive  hypersemia  and  its  frequent  sequel, 
ansemia,  mention  has  been  made  of  collateral  hypercemia  often 
following  this  or  any  other  form  of  ansemia  [vide  prognosis  of 


56  DISEASES   OP   THE   NERVOUS   SYSTEM. 

hypersemla).  It  may  be  that  the  correct  interpretation  of  this 
expression  has  not  been  seized,  and  hence  an  elucidation  of  what 
is  meant  becomes  necessary.  This  collateral  hyperaemia  is  nothing 
more  than  a  diversion  of  the  blood,  the  simple  result  of  some 
other  pathological  condition.  Supposing  the  quantity  of  blood  to 
remain  the  same  in  the  brain  when  in  a  strictly  physiological 
condition,  it  is  evident,  on  the  other  hand,  that,  if  by  pressure 
during  certain  morbid  processes  the  blood  is  forced  out  of  one 
part,  there  will  be  an  undue  accumulation  of  it  in  another.  This 
is  collateral  hypersemia. 

We  have  already  seen  how  hypersemia  produces  collateral 
oedema  and  resulting  anaemia.  It  will  now  be  readily  perceived 
that  anaemia  may,  in  turn,  produce  collateral  hypersemia  of  other 
or  adjacent  parts,  which  again,  according  to  its  intensity,  may 
terminate  in  collateral  oedema,  and  often  as  a  consequence  of  this 
oedema  we  have  a  secondary  anaemia.  Hence,  whenever  there  is 
an  anaemia  in  one  part  of  the  brain,  the  patient  is  in  danger  of 
collateral  hypersemia  of  another  portion.  Collateral  hypersemia 
might  therefore  be  legitimately  added  to  the  incidental  causes  of 
local  ansemia  of  the  brain. 

Partial  hypersemia  of  the  brain  is  to  be  treated  by  the  same 
principles  that  are  applicable  to  general  diffused  cerebral  hyper- 
semia. 


LECTURE    III. 

PARTIAL   Al^r^MIA   OF   THE   BEAIN". 

Definition — Closure  of  Vessels — Collateral  (Edema — Pressure  upon  Capillaries — Throm- 
bosis— Embolism — Rheumatism — Thrombosis  as  a  Cause  of  Embolism — Aneurism  as 
a  Cause — Artificial  Production  of  Embolism — Effects  of  Closure — Collateral  Circula- 
tion— Ligation  of  Carotid  in  Man ;  in  Animals — Embolism  in  Left  Side — Why  the 
Right  Side  is  generally  paralyzed — Fissure  of  Sylvius — Brain  not  Gangrenous — Cause 
of  Absence  of  Gangrene — Cause  of  Presence  of  Gangrene — Collateral  Hyperaemia — 
Secondary  Anamia — Compression  of  Capillaries — Change  of  Color — Hemorrhagic  In- 
farction— Size  of  Softened  Parts — Anatomical  Condition  in  Ansemia — Pathological 
Efi"ects  of  Pressure — Symptoms  of  Softening  of  the  Brain — Degrees  of  Functional 
Derangement — Symptoms  of  Excitation  and  of  Depression :  Amnesia,  Agraphia, 
Aphasia,  Hemiplegia — Peripheral  Arteries — Variation  of  Symptoms — DLfferentiation 
between  Embolism  and  Cerebral  Hemorrhage — Differentiation  between  Thrombosis  and 
Embolism — Symptoms  of  Anaemia  from  Collateral  (Edema — Obscure  Diseases  ex- 
plained by  Collateral  (Edema — Explanation  of  Phenomena  of  Clot — Symptoms  of 
Pressure  by  Abscesses,  Tumors,  etc. — Obscurity  of  Diagnosis  in  Brain-Diseases — 
Views  of  Charcot,  Cohnheim,  Heubner,  and  Duret  upon  the  Terminal  Cerebral  Arte- 
ries— Charcot's  Recent  Teachings  upon  the  Pathological  Anatomy  of  Cerebral  Softening. 

Gentlemen, — Anasmia,  as  the  term  implies,  is  a  deficiency 
of  blood,  as  regards  quantity.  It  is,  therefore,  the  opposite  path- 
ological condition  to  hyperaemia.  Partial  anaemia  of  the  brain, 
according  to  Niemeyer's  classification,  is  dependent  upon  several 
causes,  that  can  be  placed  under  three  heads,  as  follows : 

1.  Closure  of  the  affei^ent  blood-vessels.  The  anaemia  from  this 
cause  may  be  general  or  partial :  it  is  general  when  the  entire 
encephalon  is  involved,  and  partial  when  limited  to  one  hemi- 
sphere, or  to  a  portion  thereof.  In  the  majority  of  cases  we 
have  only  a  partial  anaemia. 

2.  Collateral  oedema.  This  is  a  transudation  of  the  serum  of 
the  blood  into  the  surrounding  tissues.  This  serum  presses  upon 
the  capillaries,  and  is  the  general  result  of  active  or  passive 
hyperaemia.  We  have  already  noted  its  effects  while  reviewing 
hyperaemia,  and  it  is  evident  that,  in  this  connection,  we  might 
name  hyperaemia  as  one  of  the  indirect  causes  of  anaemia. 

57 


58  DISEASES   OF   THE  NEEVOUS   SYSTEM. 

3.  Pressure  upon  the  capillaries  by  tumors,  abscesses,  clots  of 
blood,  etc.  In  all  instances  we  have  softening  of  the  brain  as  a 
direct  result  of  a  continued  exclusion  of  blood  therefrom.  Let 
us  consider  each  of  these  causes.  First  we  have  closure  of  the 
afferent  blood-vessels ;  this  is  produced  principally  by  two  patho- 
logical conditions, — thrombosis  and  embolism. 

It  happens  in  certain  affections  that  the  blood  is  not  properly 
propelled  through  the  vessels.  This  may  occur  in  various  ways. 
The  arteries  are  all  supplied  with  a  fibro-muscular  coat,  controlled 
by  the  vaso-motor  nerve  accompanying  the  vessel.  This  insures 
the  contraction  and  relaxation  of  the  artery,  actions  both  com- 
pensatory and  essential  to  the  proper  maintenance  of  the  circula- 
tion. Arterial  elasticity  and  contractility  may  be  lessened  by  the 
pressure  of  tumors  upon  the  artery,  or  more  particularly  by  dis- 
ease of  the  vessels  themselves,  as,  for  instance,  calcareous  degen- 
eration, or  inflammatory  action,  which  gives  rise  to  a  disease 
termed  endo-arteritis  deformans,  especially  liable  to  attack  aged 
people.  ]S[ow,  a  result  of  this  deficient  propulsion  of  the  blood 
is  a  retardation  of  the  circulation,  the  inner  surface  of  the  arterial 
trunks  being  roughened,  a  deposit  of  fibrin  sooner  or  later  occur- 
ring. This  process  is  a  slow  one,  and  takes  place  also  in  the 
smaller  arteries,  greatly  impeding,  if  not  preventing,  the  re- 
establishment  of  the  collateral  circulation.  For  it  must  be  borne 
in  mind  that  in  endo-arteritis  deformans  the  arterioles  are  in 
precisely  the  same  condition,  pathologically,  as  the  trunks,  and,  in 
consequence  of  their  non-dilatability,  the  collateral  circulation  is 
not  effected.  The  clot  or  fibrinous  deposit  above  described  is 
called  a  thrombus,  and  always  occurs  in  situ  ;  that  is,  we  find  it 
where  the  pathological  conditions  above  described  are  most  active. 
In  inflammatory  affections  the  blood  is  hyperinotic,  and  conse- 
quently will  more  readily  deposit  its  fibrin,  and  so  in  arteritis  we 
find  a  concurrence  of  conditions  very  favorable  for  the  production 
of  thrombosis. 

The  effects  of  thrombosis  do  not  materially  differ  from  those 
of  embolism.  We  have  already  seen  that  a  thrombotic  clot  ob- 
structs the  circulation  at  the  place  of  its  formation.  "When  a 
clot  obstructs  a  vessel  at  a  point  distant  from  the  place  of  its 
formation,  it  is  called  an  embolus.  The  latter  condition  is 
characterized  by  suddenness  of  invasion,  and  the  vessels  whose 


PAETIAL   ANiEMIA   OF   THE   BRAIN.  59 

walls  confine  or  arrest  it  in  its  course  may  themselves  be  in  an 
entirely  normal  condition.  An  embolus  may  be  liberated  from 
different  organs  of  the  body,  the  lungs,  heart,  etc.,  and  it  may 
be  as  varied  in  composition  as  are  its  points  of  departure.  An 
embolus  is  generally  conveyed  from  the  heart,  and  is  usually 
fibrinous. 

Different  abnormal  states  of  the  system  predispose  to  conditions 
of  the  cardiac  valves  and  orifices  which  may  subsequently  induce 
embolism.  Rheumatism  is  a  very  common  cause.  In  this  affec- 
tion, due  to  a  peculiar  materies  morhi,  there  is  an  inflammation  of 
the  several  fibrous  tissues  of  the  body,  and  there  is  frequently 
developed  a  pericarditis,  endocarditis,  or  thickening  of  the  auric- 
ulo-ventricular,  aortic,  and  pulmonary  valves.  A  deposit  of  fibrin 
follows,  with  the  formation  of  concretions  and  vegetations,  parts 
of  which  may  be  detached  by  the  current  of  the  blood,  carried 
away  from  the  heart,  and  produce  embolism  in  some  distant 
artery.  Or,  if  the  original  source  of  the  embolus  is  very  friable, 
it  may,  as  Yirchow  has  shown,  break  up  into  minute  fragments 
and  constitute  capillary  emboli. 

Thrombosis  may  sometimes  be  the  cause  of  embolism,  when,  for 
instance,  the  thrombus  is  formed  in  a  vein  as  a  result  of  phlebitis, 
and  a  portion  of  its  substance,  becoming  detached,  is  carried  away 
in  the  venous  current.  When,  on  the  contrary,  it  occurs  in  an 
arter}\  it  closes  the  artery,  and  cannot  be  conveyed  along  by  the 
current  of  blood,  on  account  of  the  diameter  of  the  vessel  grad- 
ually diminishing.  But  the  venous  blood  is  conducted  by  vessels 
whose  diameters  increase  in  the  direction  of  the  current.  There- 
fore, where  a  thrombus  forms,  as  in  phlebitis  occurring  in  certain 
puerperal  and  other  conditions  (coagulation  in  the  uterine  sinuses, 
etc.),  the  clot,  or  a  portion  of  it,  becomes  detached,  and  is  carried 
along  to  the  right  auricle,  right  ventricle,  pulmonary  artery,  and 
finally  lodges,  according  to  its  size,  in  one  of  the  larger  or  smaller 
pulmonary  vessels.  It  is,  therefore,  evident  that  when  a  throm- 
bus in  a  vein  results  in  embolism,  the  embolus  will  always  be 
arrested  in  the  lungs  or  in  the  trunk  of  the  pulmonary  artery  or 
some  of  its  branches. 

As  the  main  cause  of  cerebral  thrombosis  (endo-arteritis  defor- 
mans) affects  only  persons  who  have  passed  the  meridian  of  life, 
it  materially  differs  from  embolism  in  this  respect,  that  the  latter 


60  DISEASES   OF   THE   NERVOUS   SYSTEM. 

is  not  confined  to  any  age,  and  may  occur  at  any  moment  and 
under  varying  conditions. 

Embolism,  as  has  been  previously  stated,  may  be  produced  by 
a  diversity  of  causes,  though  it  generally  originates  in  the  heart. 
It  has  been  known  to  result  from  the  handling  of  an  aneurism 
containing  a  clot  of  fibrin,  whereby  the  clot  or  a  portion  of  it 
became  detached,  and  the  patient  perished.  Physiological  experi- 
ments have  been  made  with  the  view  of  producing  embolism 
artificially,  and  this  has  been  done  by  the  injection  of  solid  foreign 
bodies,  such  as  millet-seeds,  etc.,  into  the  blood-vessels  of  ani- 
mals, producing  a  closure  of  the  afferent  vessels,  and  resulting  in 
disturbances  of  the  circulation  in  the  organs  aifected. 

I  will  next  consider  some  of  the  effects  of  closure  of  the  ves- 
sels supplying  the  cerebrum  with  blood.  Suppose  the  left  middle 
cerebral  artery  to  be  suddenly  plugged, — and  a  very  important 
one  it  is,  supplying  a  part  of  the  hemisphere  with  blood.  The 
first  result  will  be  an  anaemia  of  that  portion  of  the  hemisphere 
which  cannot  receive  its  blood-supply  from  the  artery,  now  no 
longer  pervious,  and,  if  it  be  not  relieved,  that  hemisphere  will 
cease  to  perform  its  functions,  and,  the  condition  persisting,  there 
will  be  a  lack  of  nutrition,  and,  as  an  inevitable  consequence, 
softening. 

We  have  said,  when  speaking  of  thrombosis,  that  in  this 
morbid  state  the  arterioles  are  in  the  same  condition  as  the 
trunks,  having  lost  their  resiliency,  which  is  so  eminently  neces- 
sary for  the  normal  propulsion  of  the  blood.  It  therefore  fol- 
lows that  the  collateral  circulation  cannot  be  established.  How 
is  it  La  embolism,  where  no  pathological  state  of  the  collateral 
vessels  exists?  Farther  on  it  will  be  seen  that  it  depends  en- 
tirely upon  the  situation  of  the  artery  which  lodges  the  embolus 
whether  or  not  the  collateral  circulation  will  be  developed,  and 
also  whether  the  artery  be  a  terminal  one  or  not.  If  the  em- 
bolus be  lodged  in  an  artery  helow  the  circle  of  Willis,  the  col- 
lateral circulation  ^vill  quite  possibly  occur;  but  such  will  not 
be  the  case  if  the  plug  or  embolus  be  in  an  artery  above  the 
circle  of  Willis,  and  the  portions  of  the  brain  deprived  of  their 
blood-supply  will  become  anaemic,  because  the  other  vessels  Mdll 
not  be  adequate  to  send  a  sufficiency  of  blood  to  supply  the 
territory  deprived  of  its  nutrient  fluid.     Where  rheumatism,  for 


PAKTIAL   ANEMIA   OF   THE   BRAIN.  61 

instance,  is  the  predisposing  cause,  there  is  first  an  embohis  pro- 
ducing anaemia,  and  this  condition  will  eventuate  in  softening, 
and  lastly  hemiplegia,  with  more  or  less  abolition  of  the  psychical 
and  motor  functions,  more  or  less  pronounced,  according  to  the 
site  of  the  pathological  lesion.  Whenever,  therefore,  the  embolus 
lodges  above  the  circle  of  Willis,  there  is  no  probability  of  re- 
covery from  the  disease,  though  life  may  be  prolonged  by  com- 
pensatory action  of  the  opposite  cerebral  hemisphere.  It  is,  for 
this  reason,  plainly  a  much  more  favorable  condition  for  the  clot 
to  lodo;e  below  the  circle  of  Willis  ;  but  even  then  the  situation  is 
sometimes  grave,  for  in  man  there  are  difficulties  opposing,  or  at 
least  unfavorable  to,  the  establishment  of  the  collateral  circulation, 
and  softening  very  often  results.  In  corroboration  of  this  state- 
ment may  be  cited  the  well-known  fact  of  softening  sometimes 
ensuing  upon  ligation  of  one  of  the  carotids.  This  should  not 
deter  the  surgeon  from  ligating  either  of  these  arteries  where 
necessity  demands  it.  In  certain  animals  the  tendency  always 
seems  to  be  in  favor  of  the  re-establishment  of  the  circulation,  and 
experiments  have  been  made  upon  rabbits,  where  no  bad  effects 
ensued  from  the  ligation  of  three  of  the  four  supplying  arteries. 
Of  course,  where  the  softening  occurs  on  the  left  side  of  the  brain, 
the  hemiplegia  will  be  upon  the  right  side  of  the  body ;  and  you 
will  find  it  to  be  a  well-known  clinical  fact  that  the  right  side  is 
generally  the  one  paralyzed.  The  reason  of  this  is  simple.  The 
right  common  carotid  artery  arises  from  the  arteria  innominata, 
while  the  left  arises  directly  from  the  arch  of  the  aorta,  and  is, 
therefore,  more  in  the  line  of  direction  of  the  arterial  current; 
hence  it  follows  that  an  embolus  from  the  heart  vnW  more  readily 
enter  the  left  than  the  right  carotid.  The  embolus  is,  therefore, 
frequently  arrested  in  the  left  middle  cerebral  artery,  in  the  fissure 
of  Sylvius.  Upon  autopsy,  it  is  always  prudent  to  examine  this 
artery,  especially  when  other  anatomical  explorations  have  offered 
only  negative  results. 

Another  point  which  it  is  well  to  refer  to  is  that  the  softened 
brain  does  not  become  gangrenous,  although  Niemeyer  speaks 
very  truly  of  the  condition  present  being  one  of  necrosis.  It 
softens,  liquefies,  becomes  disorganized,  but  it  does  not  putrefy  or 
become  fetid.  The  different  influences  (of  atmosphere,  tempera- 
ture, etc.)  which  are  requisite  for  such  a  condition  are  almost  en- 


62  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tirely  excluded,  the  brain  being  closely  confined  and  hermetically 
protected  by  the  skull.  Nevertheless,  you  may  find  offensive  ab- 
scesses or  putrid  collections  within  the  skull ;  but  this  happens 
only  when  the  embolus  originated  in  a  necrosed  point — namely, 
an  infectious  embolus — ^and  carried  the  infection  with  it  from 
the  source  whence  it  emanated.  We  may  have  such  a  condition 
of  things  in  certain  pulmonary  affections,  as  in  tuberculosis, 
where  there  is  considerable  tissue-metamorphosis  occurring,  and 
a  miQute  portion  of  gangrenous  lung  is  detached,  carried  through 
the  pulmonary  veins  to  the  left  auricle  and  ventricle,  whence  it 
goes  to  the  brain,  or  possibly  to  some  other  part  of  the  body. 
But,  wherever  it  goes,  it  carries  the  putrefactive  ferment  with  it, 
which  will  be  communicated  to  any  part  in  which  it  may  chance 
to  be  lodged. 

As  we  have  already  spoken  of  hypersemia  and  collateral  oedema 
as  the  second  cause  of  anaemia  (vide  post-mortem  in  hypersemia, 
also  causes  of  ansemia),  very  little  remains  to  be  added  in  this 
connection ;  but  there  is  still  one  point  necessary  to  be  dwelt  upon. 
In  speaking  of  excessive  hypersemia  and  its  sequel  ansemia  in  a 
preceding  lecture,  mention  has  been  made  of  collateral  hyperoemia 
often  following  this  or  any  other  form  of  ansemia  [vide  prognosis 
of  hypersemia).  It  may  be  that  the  correct  interpretation  of  this 
expression  has  not  been  seized,  and  hence  an  elucidation  of  what 
is  meant  becomes  necessary.  This  collateral  hypersemia  is  nothing 
more  than  a  diversion  of  the  blood,  the  simple  result  of  some 
other  pathological  condition.  Supposing  the  quantity  of  blood 
to  remain  the  same  in  the  brain  when  in  a  strictly  physiological 
condition,  it  is  evident,  on  the  other  hand,  that  if  by  pressure 
during  certain  morbid  processes  the  blood  is  forced  out  of  one 
part,  there  will  be  an  undue  accumulation  of  it  in  another.  This 
is  collateral  hypersemia. 

Anything  producing  undue  pressure  within  the  cranial  space 
will  cause  ansemia  of  the  brain.  The  particular  manner  in  which 
the  capillary  compression  and  subsequent  ansemia  are  brought 
about  will  hereafter  be  considered.  For  the  present  it  is  sufficient 
to  concede  the  possibility  of  a  partial  pressure  on  the  brain.  The 
question  naturally  arises,  "  How  is  it  possible  to  have  a  partial 
or  limited  pressure?  Pressure  being  continuous  from  molecule 
to  molecule,  it  will  not  be  localized."     This  conclusion  is  erro- 


PAKTIAL   ANEMIA   OF   THE   BRAIN.  63 

neous,  having  been  arrived  at  by  fallacious  reasoning.  It  was 
sapjDosed,  as  Niemeyer  states,  that  the  condition  was  analogous 
to  that  of  a  bottle  filled  with  liquid  in  which  a  cork  is  being 
forcibly  driven.  The  bottle  will  break  at  its  weakest  point,  and 
not  at  the  point  where  the  pressure  is  directly  applied.  There 
is  then  a  transmission  of  pressure,  contuiuous  and  without  inter- 
mission, and  this  pressure  is  applied  to  the  Avhole  bottle,  and  not 
localized.  In  this  conclusion,  as  the  last-mentioned  author  adds, 
a  great  fact  was  overlooked, — viz.,  the  anatomical  division  of  the 
brain  by  the  falx  cerebri.  The  cerebrum  is  essentially  a  dual 
organ,  and  is  thus  equally  divided  into  hemispheres;  and  by 
stdl  another  membrane,  the  tentorium  cerebelli,  the  encephalon  is 
subdivided  into  three  portions. 

Now,  it  is  evident  that  if  pressure  of  a  certain  degree  (patho- 
logical or  traumatic)  be  applied  to  one  of  these  distinct  portions 
of  the  brain,  the  membranes  above  mentioned  will  effect  a  limi- 
tation of  it  to  the  hemisphere  to  which  it  has  been  originally 
applied,  the  other  hemisphere  remaining  substantially  unaffected. 
This  same  law  applies  to  the  cerebellum,  which  may  be  diseased 
or  suffer  from  hemorrhage  without  the  cerebrum  being  perni- 
ciously influenced,  though  not  invariably  so ;  as  it  may  happen 
that  the  pressure  applied  may  be  very  great  and  thus  extend 
beyond  a  certaiu  limit,  when,  of  course,  the  membranes  would 
yield.  This  occurs  very  seldom.  It  is  clear  that  sometimes  a 
circumscribed  pressure  exists  in  the  brain,  in  no  degree  trans- 
mitted to  distant  parts ;  and  in  this  case  you  will  understand  that 
a  tumor,  for  instance,  can  exercise  pressure,  and  produce  regional 
symptoms  due  to  a  partial  anaemia. 

In  what  manner  does  capillary  compression  (from  abscesses,  etc.) 
produce  anaemia  of  the  brain?  In  the  simplest  way  possible. 
Imagine  a  sponge  filled  with  water  and  resting  in  the  palm  of  the 
hand.  The  moment  the  fingers  are  flexed  upon  it,  the  sponge  is 
compressed  and  the  water  exudes.  In  this  manner  will  a  clot, 
abscess,  etc.,  pressing  upon  the  capillaries,  force  the  blood  from 
them,  and  produce  anaemia  in  the  immediate  vicinity. 

THE   PATHOLOGICAL   ANATOMY  OF   CEREBRAL  ANEMIA. 

When  speaking  of  the  post-mortem  appearances  of  the  brain 
in  hyperaemia,  it  was  noticed  that  the  result  of  our  examination 


64  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

was  often  unsatisfactory  and  deceptive,  and  that  while  looking  for 
a  hypersemic  brain  we  might  find  one  which  was  ansemic.  These 
apparent  anomalies  and  difficulties  again  meet  us  in  anaemia. 
During  life  the  anaemic  condition  of  certain  parts  is  readily  recog- 
nized. For  instance,  in  the  face  we  note  the  skin,  which,  owing 
to  its  rich  vascularity,  is  very  prone  to  show  an  ansemic  con- 
dition, even  while  the  vital  processes  are  still  active.  But  after 
death  we  no  longer  expect  to  see  the  healthy,  rosy  hue,  but 
rather  a  pale,  leaden,  cadaverous  look,  and  from  this  we  draw 
absolutely  no  information  in  regard  to  excessive  or  diminished 
vascularity  during  life.  After  death,  hypersemic  parts  often  look 
ansemic,  and  ansemic  parts  appear  hypersemic,  from  the  gravita- 
tion of  the  blood  and  its  settling  after  the  cessation  of  circulation  : 
thus  there  are  many  causes  which  are  apt  to  lead  us  into  error. 
But  we  do  know  that,  as  a  consequence  of  persistent  ansemia, 
softening  ensues,  and  that,  if  the  ansemia  be  intense  enough,  even 
liquefaction  of  the  ansemic  parts  may  result.  Therefore,  softening 
is  the  condition  we  have  to  look  for  as  corroborative  evidence  of 
persistent  and  complete  ansemia,  and  it  is  easily  determined  by 
pouring  a  gentle  stream  of  water  on  the  brain,  when  the  softened 
parts  will  appear  more  or  less  disintegrated,  according  to  their 
different  conditions,  and  be  washed  away. 

It  happens  that  the  brain,  in  various  forms  of  softening,  pre- 
sents either  a  whitish,  yellowish,  or  reddish  appearance ;  but  there 
is  nothing  in  this  to  claim  our  particular  attention.  There  is 
another  condition  not  to  be  overlooked, — viz.,  hemorrhagic  infarc- 
tion. Here  the  brain  is  dotted  with  a  bloody  tint,  from  minute 
capillary  extravasations ;  but  this  is  caused  by  embolism  of  one  or 
more  arterial  trunks.  In  embolism  there  is  always  this  tendency 
to  capillary  rupture  and  hemorrhage.  This  occurs  in  the  lung  or 
in  other  organs  just  as  readily  as  in  the  brain  ;  in  fact,  wherever 
the  embolus  happens  to  be  arrested.  This  is  mentioned  only  to 
warn  the  student  from  mistaking  these  minute  extravasations  for 
the  appearances  of  hypersemia  when,  in  reality,  ansemia  exists. 

The  extent  of  the  softened  parts  is  exceedingly  variable,  being 
from  the  size  of  a  pea  to  that  of  a  hen's  egg,  or  even  larger.  It 
sometimes  happens  that  large  portions  of  the  brain  are  softened 
without  any  grave  symptoms  being  manifested  during  life.  This 
depends  entirely  upon  the  importance  of  the  parts  implicated ;  and 


PARTIAL   ANEMIA    OF   THE   BRAIX.  65 

although  softening  of  the  medullary  fibres  of  the  cerebrum  might 
not  be  attended  with  many  or  any  symptoms,  it  is  evident  that 
in  other  parts,  as  the  medulla  oblongata  or  the  cortical  portions 
of  the  brain,  softening  would  give  rise  to  serious  and  unmistakable 
symptoms.  In  some  cases  of  brain-disease,  whether  the  patient 
dies  from  an  acute  or  from  a  chronic  affection,  we  may  often  be 
sorely  puzzled  as  to  the  diagnosis,  and  post-mortem  examination 
may  show  nothing  satisfactory  to  explain  the  symptoms  which 
were  present  during  life.  In  such  cases  it  is  always  well  to 
examine  the  left  middle  cerebral  artery,  and  we  will  frequently 
find  it  obstructed,  more  particularly  so  when  sudden  paralysis 
occurred  during  life.     (See  Embolism  and  Thrombosis.) 

The  anatomical  condition  in  anaemia  and  collateral  oedema  is 
very  important.  The  post-mortem  examination  -will  reveal,  in 
some  instances,  a  pearly,  glistening  lustre  in  the  ansemic  parts, 
and  the  scalpel  will  be  wet  or  moist  with  serum. 

Among  the  ordinary  pathological  manifestations  of  great  press- 
ure is  a  marked  depression  of  the  sulci ;  the  brain,  being  full  of 
serum,  tends  to  swell,  and,  as  compared  with  a  healthy  brain,  is 
remarkably  white.  Or  we  may  have  a  protrusion  of  the  tentorium 
cerebelli,  or  of  the  falx  cerebri,  which  may  dip  to  one  side  from 
pressure  on  the  other,  or  the  pressure  existing  in  the  lower  part 
of  one- hemisphere  may  cause  a  dipping  of  the  tentorium  cerebelli. 
In  both  instances  it  will  depend  upon  the  amount  and  cause  of 
pressure,  and  in  mild  forms  of  disease  may  escape  observation 
altogether. 

SYMPTOMS   OF  SOFTENING  OF   THE   BRAIN. 

The  causes  of  partial  ansemia,  followed  by  partial  softening, 
are  all  that  we  have  thus  far  analyzed.  General  ansemia  will  be 
investigated  at  a  future  time. 

In  considering  the  symptoms  of  softening,  two  important  facts 
must  be  borne  in  mind  :  1st,  there  are  no  pathognomonic  symp- 
toms of  softening ;  2d,  the  symptoms  of  anaemia  and  of  hyper- 
emia are  generally  very  similar.  Consequently,  a  reliance  upon 
any  one  symptomatic  indication  will,  in  most  cases,  lead  us  astray. 
Inasmuch  as  the  treatment  in  certain  cases  is  of  the  highest  impor- 
tance, it  is  necessary  to  make  a  correct  differential  diagnosis  to 
arrive  at  proper  conclusions.    This  diagnosis  can  be  made  only  by 

5 


66  DISEASES   OF   THE   NERVOUS  SYSTEM. 

patient,  deliberate,  and  careful  investigation  of  the  history  of  the 
case,  and  by  becoming  conversant  with  all  the  pathological  and 
etiological  facts  and  data  obtainable.  "We  have  seen  that,  although 
this  knowledge  is  very  needful,  the  student  must  be  careful  not 
to  be  too  exclusively  guided  or  biassed  by  any  single  deduction  : 
whilst  mindful  of  the  pathological  laws  of  softening,  he  must 
carefully  weigh  and  consider  the  history  and  probable  cause  of 
the  disease.  With  Kiemeyer,  I  would  urge  you  to  have  due  re- 
spect for  the  sequence  of  events  and  symptoms  in  a  given  case. 
By  the  term  sequence  is  meant  the  manner  in  which  the  events  or 
symptoms  succeed  each  other.  This  will  often  enable  you  to  draw 
pretty  correct  inferences  as  to  the  probable  cause  of  the  disease.  1  f 
the  phenomena  are  characterized  by  suddenness,  you  may  infer 
embolism ;  if,  on  the  other  hand,  the  symptoms  have  been  slow 
in  development,  you  may  presume  it  to  be  thrombosis,  provided 
youth  does  not  exclude  the  conclusion.  To  obviate  every  source 
of  error,  I  will  successively  take  up  all  the  forms  and  correspond- 
ing symptoms  of  anaemia. 

Syphilitic  disease  of  the  arteries  frequently  leads  to  softening, 
as  we  will  explain  more  definitely  in  another  lecture.  (See  lec- 
ture on  "  Syphilitic  Nervous  Affections,"  vol,  ii.) 

The  following  law  must  first  be  established  :  whenever  there  is 
a  sudden  shutting  off  of  a  considerable  supply  of  arterial  blood 
from  a  part  of  the  brain,  there  will  be  an  interruption  in  the  func- 
tions of  that  part  which  will  be  in  direct  proportion  to  the  amount 
of  blood  excluded.  If  the  blood-supply  has  only  been  diminished, 
a  partial  or  limited  suspension  of  the  functions  of  the  part  will 
be  the  result ;  but  if  the  supply  is  completely  shut  off  from  an 
important  artery,  there  will  be  an  entire  suspension,  in  fact,  an 
abolition,  of  the  physiological  actions  involved. 

In  anaemia  of  the  brain  we  find  two  sets  of  symptoms :  those 
of  excitation  and  those  of  depression.  These  symptoms  may  exist 
separately,  or  in  combination,  or  may  follow  each  other  in  alterna- 
tion. This  last  is  the  case  where  the  blood-supply  has  not  been 
entirely  suspended.  As  the  disease  advances  and  the  calibre  of 
the  artery  grows  smaller,  the  symptoms  of  excitation  diminish, 
while  those  of  depression  increase.  Where  the  symptoms  of 
depression  alone  exist,  and  persist,  we  may  infer  a  complete 
shutting  off  of  the  arterial  supply. 


PAETIAL    ANJlMIA    OF    THE    BRAIN.  67 

The  symptoms  of  excitation  are  :  increased  or  preternatural  ex- 
citability of  the  motor,  sensory,  or  psychical  functions,  headache, 
hypereesthesia  of  the  auditory  nerve  and  of  the  nerve  of  vision, 
with  consequent  photophobia,  pain  and  symptoms  of  irritation  in 
different  parts  of  the  brain,  and  an  implication  of  all  the  nerves 
of  special  sense.  The  patient  may  feel  unusually  active  and  quick 
of  perception,  and  be  very  bright  and  uncommonly  cheerful.  This 
may  be  followed  by  a  feeling  of  lassitude  and  inactivity,  the  state 
of  depression.  In  this  state  (of  depression)  there  is  generally — 
1st,  an  impairment  of  the  mental  faculties  :  one  of  the  most  easily 
recognizable  symptoms  of  this  is  loss  of  memory ;  2d,  there  is  a 
stolid  condition  of  the  individual,  a  hebetude,  accompanied  by  an 
appearance  of  languor  and  disinclination  to  exertion,  eventuating 
in  mental  imbecility ;  3d,  the  judgment  becomes  impaired,  and  all 
the  mental  faculties  will  gradually  be  noticed  to  have  undergone 
a  retrograde  change,  finally  becoming  entirely  lost  or  annihilated. 
These  different  affections  are  generally  progressive,  and  we  will 
soon  observe,  more  or  less  completely  developed,  amnesia  (loss  of 
memory),  complicated  with  agraphia  and  aphasia. 

In  agraphia  there  is  an  inability  to  write.  This  condition 
does  not  depend  upon  any  muscular  impediment,  but  is  simply 
the  effect  of  amnesia  :  the  patient  has  forgotten  the  alphabetical 
characters  or  the  art  of  combining  these  into  words.  Aphasia  is 
a  partial  or  complete  inability  to  remember  words,  the  symbols  of 
thought,  or  to  converse.  Here  there  is  no  difficulty  of  articula- 
tion, but  there  is  a  want  of  ability  to  recollect  the  words  which 
are  required  to  express  an  idea.  "When  certain  cortical  cells  are 
entirely  destroyed,  it  is  impossible  to  reproduce  the  memory  of 
ideas. 

And  so  with  the  affections  of  the  motor  system.  If  the  attack 
be  sudden,  motion  is  usually  at  once  destroyed.  If  it  be  gradual, 
we  have,  first,  a  limited  paralysis,  affecting  only  a  few  muscles  in 
the  beginning ;  then  the  paralysis  extends  and  attacks  another 
part,  and  so  on  until  gradually  an  entire  and  permanent  hemi- 
plegia finally  results.  I  say  hemiplegia,  because,  as  yet,  we  are 
dealing  with  partial  anremia. 

Kow,  what  are  the  symptoms  peculiar  to  anaamia  the  result 
of  thrombosis,  embolism,  collateral  oedema,  or  pressure  upon  the 
capillaries  ? 


68  DISEASES   OF   THE   NERVOUS   SYSTEM. 


THROMBOSIS. 

Thrombosis,  unless  relieved,  ends  in  softening  of  the  brain, 
which  is  the  result  we  are  to  anticipate.  How  are  we  to  recognize 
this  disease,  either  in  the  recent  or  the  advanced  stage  ?  Though 
it  is  sometimes  difficult  to  make  the  diagnosis,  it  is  in  most  cases 
possible  to  do  so ;  and  although  you  may  not  be  absolutely  cer- 
tain, you  will  nearly  always  recognize  the  leading  features  of  the 
affection.  Of  course  you  have  to  keep  well  in  mind  everything 
connected  with  the  development  of  the  case,  and  be  very  careful 
in  analyzing  the  ascertained  facts. 

Thrombosis,  a  result  of  a  diseased  condition  of  the  arteries 
(endo-arteritis  deformans),  usually  occurs  in  persons  quite  ad- 
vanced in  years.  Hence  age  is  signiiicant,  and  must  not  be  lost 
sight  of  in  your  examinations.  You  would  hardly  think  of 
diagnosticating  thrombosis  in  a  young,  healthy,  vigorous  man; 
but  where  the  patient  has  passed  the  meridian  of  life,  such  a 
diagnosis  would  have  just  grounds  to  rest  upon.  But,  as  age 
alone  is  not  a  sufficient  fact  upon  which  to  base  your  diagnosis, 
you  must  have  recourse  to  other  considerations. 

Great  importance  has  been  attached  by  some  authors  to  the 
condition  of  the  peripheral  arteries  as  a  diagnostic  sign  of  throm- 
bosis. Of  course  it  is  probable  that  if  a  diseased  condition  of  the 
arteries  exist  in  the  brain  it  may  also  exist  from  the  same  cause 
in  other  portions  of  the  body.  This  may  be  the  case  at  times, 
but  it  is  by  no  means  so  invariably.  We  may  have  endo-arteritis 
deformans  in  the  cranium  and  yet  not  have  it  in  any  other  portion 
of  the  body,  or,  vice  versa,  it  may  exist  in  some  other  organ  and 
still  be  al^sent  in  the  brain.  So  that  the  evidence  furnished  by 
the  diseased  condition  of  the  peripheral  arteries  may  sometimes 
be  confirmatory,  but  nothing  more. 

The  condition  of  atheromatous  degeneration  of  the  arteries  in 
any  accessible  part  of  the  body  is  not  very  difficult  to  recognize. 
We  generally  have  in  affected  vessels  a  characteristic  atheromatous, 
.  retrograde,  inflammatory  condition, — the  artery  being  preternatu- 
rally  tortuous,  rigid,  and  unyielding,  without  resiliency,  and  offer- 
ing to  the  touch  of  the  experienced  observer  an  inelasticity  whose 
peculiarity  he  will  immediately  recognize ;  though  if  the  patient 
has  exhibited  chronic  brain-symptoms  in  connection  with  a  certain 


PAETIAL    AXiEMIA    OF    THE    BRAIN.  69 

advanced  age,  and  superadded  to  this  we  have  the  condition  of 
the  peripheral  arteries  just  referred  to,  there  is  a  strong  presump- 
tion of  thrombosis. 

Still,  this  presumption  is  not  a  certainty,  and  we  need  one  link 
more  in  the  chain  of  pathological  evidence  to  make  our  diagnosis 
sure.  This  will  be  furnished  by  a  study  of  the  positive  and 
rational  symptoms,  which  are  those  of  irritation  and  of  depres- 
sion, and  these  symptoms  will  alternate  or  vary  in  obstinacy  or 
intensity.  Paralysis  comes  on,  disappears,  or  returns ;  a  patient 
will  be  very  bright  one  day,  and  correspondingly  dull  the  fol- 
lowing day.  This  variation  has  been  incorrectly  considered  to  be 
pathognomonic  of  softening.  It  may  be  characteristic  of  antemia, 
but  certainly  is  not  so  of  softening ;  which  latter  condition,  being 
a  result  of  profound  anaemia,  is  persistent,  admitting  of  no  pos- 
sible variation  of  symptoms.  In  softening,  the  return  of  the 
physiological  functions  is  utterly  impossible;  they  are  entirely 
destroyed. 

This  variation  or  mutability  of  symptoms,  especially  in  paraly- 
sis, indicates  only  a  disturbance  of  the  circulation  in  the  brain,  and 
simply  points  to  alternations  in  the  extent  of  the  anaemia.  But 
when  once  a  part  of  the  brain  is  perfectly  and  permanently 
ansemic,  it  softens ;  and  when  there  is  no  variation  in  the  symp- 
toms present,  it  points  to  total  abolition  of  those  functions  which, 
for  their  proper  performance,  depend  upon  the  integrity  of  the 
part  of  the  brain  presiding  over  their  evolution.  The  disturb- 
ances of  the  circulation  are  due  to  the  following  facts :  1st,  the 
gradual  narrowing  of  the  calibre  of  the  arteries  ;  2d,  the  alterna- 
tions of  anaemia  and  collateral  hyperaemia,  the  accession  of  which 
produces  disordered  vascular  action  and  corresponding  symptoms. 
But  in  thrombosis  the  resulting  ansemia  is  more  slowly  produced, 
as  are  also  the  changes  in  structure,  causing  a  gradual  development 
of  symptoms,  the  manifestations  of  definite,  progressive  patho- 
logical lesions. 

To  recapitulate,  we  find  in  thrombosis : 

1st.  The  state  of  advanced  age.  2d.  The  gradation  and  dura- 
tion of  the  symptoms.  3d.  The  variations  of  the  symptoms. 
4th.  The  morbid  condition  of  the  peripheral  arteries ;  though  this 
is  not  necessarily  present. 


70  DISEASES   OF  THE   NERVOUS   SYSTEM. 


EMBOLISM. 

Embolism  is  generally  easily  recognized,  its  symptoms  being 
quite  plain,  and  its  consequences  obvious. 

When  a  man  evinces  symptoms  of  softening  of  the  brain, 
embolism  suggests  itself.  Without  a  characteristic  suddenness  in 
the  appearance  of  the  symptoms,  there  is  no  embolism.  In  order 
to  obtain  confirmatory  evidence,  inquire  at  once  into  the  history 
of  the  case ;  and  should  you  ascertain  that  your  patient  has  been 
subject  to  frequent  rheumatic  attacks,  you  will  examine  the  heart, 
and,  detecting  a  bruit  (diastolic  or  systolic),  may  confidently  diag- 
nose embolism.  Do  not  fail,  therefore,  to  examine  the  heart  and 
lungs,  and  should  you  find,  in  addition  to  the  symptoms  already 
enumerated,  these  organs  in  a  condition  favorable  for  the  pro- 
duction of  an  embolus,  you  may  with  safety  arrive  at  the  above 
conclusion. 

I  have  already  told  you  that  embolism  occurs  mainly  with 
strikingly  marked  characteristic  symptoms,  and  that  there  is, 
therefore,  less  liability  to  be  mistaken  in  these  cases  than  in  those 
of  thrombosis ;  indeed,  the  suddenness  of  the  attack  alone  enables 
us  to  diagnosticate  with  no  little  precision. 

In  former  lectures  I  have  investigated  the  different  causes  pro- 
ducing embolism,  ha^^ing  already  stated  that  it  is  sometimes,  though 
more  rarely,  a  result  of  thrombosis  (caused  by  a  phlebitis  or  the 
puerperal  condition),  under  which  circumstances  the  embolus  will 
be  found  in  the  pulmonary  artery ;  and  I  need  hardly  add  that 
instant  death  will  certainly  result  should  its  entire  calibre  be 
obstructed. 

It  sometimes  happens  that  embolism  takes  place  in  the  spleen, 
or  in  the  liver,  conditions  which  are  of  course  extremely  difficult 
to  recognize  during  the  life  of  the  patient. 

"  An  embolus  is  a  plug  of  some  material  which  is  transported 
bv  the  blood-current  from  one  situation  to  another.  An  embolus 
may  consist  of  any  substance  which  makes  its  way  into  the  cur- 
rent of  blood.  The  majority  of  emboli  are  fibrinous,  being  de- 
rived from  thrombi.  But  emboli  may  consist  also  of  portions  of 
a  tumor  growing  within  a  vessel,  of  fragments  of  diseased  cardiac 
valves,  of  animal  and  vegetable  parasites,  of  concretions  of  lime, 
of  pigment,  of  fat,  or  of  bubbles  of  air. 


PARTIAL   AN^xMIA   OF   THE   BRAIN.  71 

"  It  is  plain  that  a  migratory  plug  or  an  embolus  can  hardly 
be  arrested  in  its  course  through  the  veins  (with  the  exception 
of  the  vena  portse),  since  the  course  of  the  blood-current  in  them 
is  from  smaller  to  larger  vessels.  Embolism,  therefore,  relates  to 
the  arteries,  with  the  single  exception  of  the  vena  portse,  while 
a  thrombus  may  be  formed  anywhere  in  the  vascular  tract.  A 
parietal  thrombus  may  be  washed  oif  partially  or  completely  by 
the  blood  flowing  over  it.  The  thrombi,  or  so-called  vegetations, 
formed  on  the  cardiac  valves  in  endocarditis  are  a  fruitful  source  of 
emboli.  An  end  of  a  thrombus  may  be  broken  oif  by  the  force 
of  the  blood-current  from  a  vessel  over  the  mouth  of  which  the 
thrombus  projects.  Finally,  fragments  may  be  detached  from 
thrombi  in  consequence  of  softening. 

"  Emboli  consisting  of  oil-globules  enter  the  circulation  most 
frequently  after  fracture  of  the  bones,  particularly  when  accom- 
panied by  extensive  laceration  of  the  marrow.  Fat  set  free  from 
marrow-cells  enters  the  open  mouths  of  ruptured  veins.  The  oil- 
drops  collect  chiefly  in  the  pulmonary  capillaries,  where  they  can 
be  recognized  only  with  the  microscope.  They  may  pass  through 
these  capillaries  and  lodge  in  the  glomeruli  of  the  kidneys,  in  the 
cerebral  capillaries,  and  in  other  capillaries  of  the  body.  In 
most  cases  emboli  of  fat  are  innocuous.  They  may,  however, 
occlude  a  sufficient  number  of  pulmonary  capillaries  to  occasion 
severe  symptoms,  or  even  death,  especially  when  the  patient  is 
already  much  prostrated.  An  excretion  of  fat  by  the  kidneys 
has  been  noticed  two  or  three  days  after  comminuted  fractures. 
Fatty  emboli  may  proceed  from  rupture  of  the  liver,  and  from 
fatty  metamorphosis  of  abscesses  and  of  thrombi. 

"  The  sudden  entrance  of  a  large  quantity  of  air  into  the  blood- 
current,  such  as  may  occur  by  incision  of  the  large  veins  in  the 
neck  or  near  the  heart,  has  been  long  known  as  the  cause  of  rapid 
death.  The  fatal  termination  is  due  to  the  accumulation  of  the 
air  in  the  right  cavities  of  the  heart,  the  contraction  of  which  is 
unable  to  force  the  elastic  air  forward.  The  air  remaining  in  the 
right  auricle  and  ventricle  forms  an  obstacle  to  the  entrance  of 
blood  from  the  venae  cavse,  and  arrests  the  pulmonary  and  sys- 
temic circulation.  .  .  . 

"  While  all  arteries  of  the  body  are  open  for  the  reception  of 
emboli,  it  is  noteworthy  that  in  certain  situations  the  obstruction 


72  DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  an  artery  by  an  embolus  is  absolutely  harmless,  whereas  in 
other  parts  it  is  followed  by  characteristic  structural  and  func- 
tional alterations.  The  main  condition  upon  which  this  differ- 
ence depends  is  the  character  of  the  arterial  distribution  in  tlie 
various  parts  of  the  body.  In  certain  organs  and  parts  of  the 
body  the  branches  of  the  arteries  do  not  anastomose  with  each 
other,  communications  existing  only  between  the  capillaries  and 
between  the  veins.  These  arteries  without  anastomoses  are  called 
by  Cohnheim  terminal  arteries  (Endarterien).  Such  arteries  are 
the  renal,  splenic,  pulmonary,  certain  of  the  cerebral,  and  the 
central  artery  of  the  retina.  The  branches  of  the  vena  portse 
also  do  not  enter  into  anastomosis  with  each  other.  When  an 
embolus  lodges  in  an  artery  supplied  with  abundant  anastomoses, 
— for  instance,  a  muscular  artery  or  one  of  the  arteries  of  the  ex- 
tremities,— a  collateral  circulation  is  established,  which  prevents 
the  part  from  suffering  in  its  nutrition  or  function.  The  effect  is 
widely  different  if  no  anastomoses  exist  between  the  peripheral 
part  of  the  occluded  *  artery  and  other  vessels.  In  this  case  no 
arterial  blood,  or  an  insufficient  amount,  is  sent  to  the  capillaries 
of  the  parts  supplied  by  the  arteries.  The  part  suffers  in  its 
nutrition,  and  may  even  undergo  necrosis  or  death. 

"  An  extravasation  of  blood  sometimes,  but  not  necessarily, 
supervenes  in  the  district  the  arterial  blood-supply  of  which  has 
been  cut  off.  These  alterations  constitute  emholio  infarctions, 
which  are  therefore  of.  two  kinds, — white  or  ancemio  infarctions 
and  hemorrhagic  infarctions.  An  embolus  produces  a  lohite  in- 
farction when  its  effect  is  anaemia  and  necrosis  without  hemor- 
rhage. Anaemic  infarctions  are  to  be  distinguished  from  decolor- 
ized hemorrhagic  infarctions,  with  which  they  were  formerly 
confounded.  The  primary  and  essential  change  in  most  white 
infarctions  is  coagulation-necrosis,  the  process  by  which  the  cells 
lose  their  nuclei  and  change  their  chemical  composition.  The 
details  of  this  peculiar  metamorphosis  will  be  described  under 
the  passive  alterations  of  the  tissues."     (Flint.) 

"  Clots  in  peripheral  veins,  however  small,  are  the  sources  of 
great  danger.  As  a  rule,  they  lead  to  secondary  and  multiple 
deposits  and  abscesses  in  the  lungs  ;  and  it  is  chiefly  differences  in 
the  size  of  the  capillary  vessels  which  determine  their  ultimate 
locality,  where  they  act  as  any  foreign  body  would.     The  debris 


PARTIAL    ANEMIA    OF   THE    BRAIN.  73 

of  clots,  and  large  cell-elements  from  clots^  in  the  mesenteric 
veins,  and  from  ulcers  of  intestines,  passing  through  the  liver 
capillaries  and  proceeding  to  the  lungs,  where  they  are  arrested, 
illustrate  this.  The  lungs  have  the  smallest  capillaries  of  all. 
They  average  from  yw^oI)  ^^  Twuwo  ^^  ^  ^^^  (scarcely  sufficient 
to  let  pass  a  white  cell  of  blood  or  of  pus,  which  on  an  average 
measures  yoVot  ^^  ^  line),  whereas  the  liver  capillaries  have  a 
much  larger  range, — namely,  from  i^Wo  ^°  TTo^oT  ^^  ^  line." 
(Aitken.) 

"  Specific  infectious  emboli  induce  pulmonary  (so-called  pyse- 
mic)  abscesses;  non-specific  emboli  produce  hemorrhagio  infarc- 
tion. Cohnheim  states  that  a  specific  plug  can  never  produce 
both  infarcts  and  abscesses.  This  view  is  not  taken  by  other 
observers."     (Loomis.) 

"  It  is  admitted  as  possible  that  thrombi  formed  in  the  left 
heart  may  break  offj  go  the  round  of  the  circulation,  and  finally 
lodge  in  some  branch  of  the  pulmonary  artery."  "  Bed-sores, 
ulcerations,  thrombosis  of  the  femoral  vein,  phlegmasia  alba 
dolens,  wounds,  and  marasmic  thrombosis  are  common  peripheral 
sources  of  emboli."     (Loomis.) 

HEMORRHAGIC   IXFARCTIOX. 

"  There  have  been  various  theories  as  to  the  source  of  the  ex- 
travasated  blood  in  hemorrhagic  infarctions.  The  explanation  ad- 
vanced by  Cohnheim,  and  derived  from  microscopical  observation 
of  the  process  in  the  tongue  of  the  living  frog,  has  been  generally 
received.  Occlusion  by  an  embolus  or  by  ligature  of  terminal 
arteries  in  the  frog's  tongue  is  followed  by  cessation  of  the  circu- 
lation on  the  peripheral  side  of  the  obstruction.  Stasis  occurs 
in  the  vessels  in  tlie  district  the  artery  of  which  is  closed.  The 
circulation  goes  on  even  with  increased  vigor  in  the  surrounding 
vessels.  The  blood-pressure  on  the  peripheral  side  of  the  obstruc- 
tion being  reduced  to  nothing,  the  blood  flows  back  from  the  veins 
which  connect  with  the  capillaries  the  arterial  supply  of  which  is 
cut  off.  These  veins  receive  their  blood  from  surrounding  veins 
from  which  the  current  has  not  been  cut  off.  The  capillaries  of 
the  obstructed  district  become  filled  with  blood  which  has  7'egurgi- 
tated  from  the  veins.  The  walls  of  these  capillaries  and  small 
veins,  not  receiving  a  fresh  supply  of  arterial  blood,  finally  become 


74  DISEASES   OF   THE   NERVOUS   SYSTEM. 

weakened  and  allow  a  diapedesis  of  the  red  corpuscles.  In  tkis 
way  Cokahemi  explains  the  formation  of  embolic  hemorrhagic 
infarctions.  Recent  experiments  of  Litten^  however,  seem  to 
show  that  the  extravasated  blood,  at  least  in  some  cases,  is  derived, 
not  by  return  flow  from  the  veins,  but  from  the  adjoining  capil- 
laries and  small  arterial  anastomoses  in  which  the  pressure  suffices 
to  send  the  blood  into  the  capillaries  of  the  part  whose  artery  is 
occluded,  but  not  onward  into  the  veins.  Litten  also  maintains 
that  many  of  Cohnheim's  terminal  arteries  are  such  only  in  an 
anatomical,  not  in  a  functional,  sense;  that  is,  when  they  are 
occluded,  blood  may  still  reach  their  capillaries  from  surrounding 
capillaries  and  small  arterial  twigs,  although  the  amount  of  blood 
may  not  suffice  for  the  nutrition  of  the  part."     (Flint.) 

We  must  again  direct  attention  to  the  influence  that  terminal 
arteries  exercise  upon  the  pathology  of  hemorrhagic  infarction 
and  cerebral  embolism.  "  None  of  the  viscera, — and  this  obser- 
vation belongs  to  Cohnheim, — where  infarctus  is  not  the  rule, 
have  the  terminal  mode  of  arterial  distribution."* 

In  this  connection  I  must  remark  that  we  cannot  always  abso- 
lutely affirm  that  anastomosis  of  the  capillaries  of  the  obliterated 
zones  supplied  by  terminal  arteries  will  not  occur. 

Duret,  of  France,  and  Heubner,  of  Leipsic,  have  contributed 
greatly  to  our  knowledge  of  the  minute  anatomy  of  the  cerebral 
circulation,  but,  unfortunately,  they  have  not  arrived  at  the  same 
conclusions  reg'ardino;  the  re-establishment  of  the  collateral  circu- 
lation  in  the  so-called  terminal  arteries  of  Cohnheim. 

I  agree  with  Charcot  that  Heubner's  facts  are  "  real,^'  but 
they  are  certainly  "rare;"  and  Duret  I  believe  is  correct  in 
stating  that,  "  if  the  arteries  of  the  encephalon  are  not  final  or 
terminal  arteries,  they  very  nearly  approach  that  type. 

"  Heubner  holds  that  the  communications  in  question  are  very 
easy,  that  they  are  made  by  the  mediation  of  vessels  not  less  than 
a  millimetre  in  diameter.  He  rests  that  assertion  upon  the  results 
of  injections,  where  he  has  invariably  observed  that  the  material 
injected  into  any  one  of  the  departments  by  a  principal  trimk,  or 
by  its  branches,  always  rapidly  penetrates  the  other  territories. 
He  also  cites  pathological  cases  which  indicate  that  obliteration 

*  Charcot,  Localization  in  Diseases  of  the  Brain. 


PAETIAL   ANEMIA   OF   THE   BRAIN.  75 

of  one  of  the  vessels  of  the  cortical  system  or  of  its  branches  has 
during  life  given  no  evident  symptom, — cases  in  which,  death 
having  followed,  the  cerebral  pulp  in  the  parts  corresponding  to 
the  obliteration  has  at  autopsy  presented  no  trace  of  softening." 

Duret,  on  the  other  hand,  says,  "  Let  ligatures  be  placed  upon 
each  of  the  three  principal  arteries  at  the  base  of  the  encephalon 
on  both  sides,  immediately  above  their  origin  in  the  circle  of 
Willis.  Then  inject  the  Sylvian  artery.  This  will  first  fill  the 
Sylvian  territory,  and  in  the  majority  of  cases  it  will  pass  beyond 
its  limits.  The  injected  material  invades  the  neighboring  parts 
slowly,  little  by  little.  This  invasion  is  made  from  the  periphery 
inwards  towards  the  centre  of  the  invaded  territory.  It  is  effected 
through  the  mediation  of  vessels  of  small  calibre  belonging  to 
the  system  of  ramifications  having  diameters  of  a  quarter  or  a 
fifth  of  a  millimetre,  contrary  to  the  opinion  of  Heubner,  who 
holds  that  these  arterial  vessels  have  a  diameter  of  one  millimetre. 

"  The  number  of  anastomoses  from  territory  to  territory  are 
also  quite  variable.  There  are  cases  where  one  of  the  three  grand 
territories  can  be  injected  isolatedly,  the  anastomoses  not  being 
sufficient  to  permit  the  injection  to  enter  the  adjacent  territories. 
The  communication  which  may  occur  at  the  periphery  of  a  vascu- 
lar territory  explains  why  the  obliteration  of  a  main  trmik  often 
results  in  the  softening  of  only  the  central  parts  of  the  territory, 
the  peripheral  portion  remaining  untouched." 

Charcot  adds,  "  It  need  not  be  supposed  that  all  obliterations 
of  this  kind  would  necessarily  and  surely  produce  such  disastrous 
effects.  There  are  rare  *  cases  where,  in  fact,  such  obliteration 
of  a  branch  of  the  Sylvian  artery,  or  even  the  artery  itself  (I 
here  take  the  Sylvian  artery  as  example ;  it  would'  be  the  same 
for  the  anterior  or  posterior  cerebral  arteries) — there  are  cases,  I 
say,  in  which  the  obliteration  in  question  has  no  appreciable,  or, 
at  least,  but  passing,  results. 

"  If  this  be  so,  it  follows  that  the  three  main  vascular  terri- 
tories into  which  the  brain  is  divided,  and  the  departments  into 
which  they  in  turn  are  separated,  are  not  strictly  isolated,  indi- 
vidual territories.  They  may  communicate,  and  indeed  do  com- 
municate in  the  ordinary  manner.     But  are  these  communications 

*  Italics  my  own. 


76  DISEASES   OF   THE   NEKVOUS  SYSTEM. 

easy  and  constant,  or,  on  the  contrary,  are  they  accidental,  indirect, 
and  often  impracticable  ?  In  the  solution  of  this  question  authors 
are  at  variance."^ 

"  Infectious  emboli,  such  as  come  from  the  cardiac  valves  in 
acute  ulcerative  endocarditis  and  from  infected  thrombi,  produce 
effects  entirely  distinct  from  the  mechanical  obstruction  to  the 
circulation.  They  incite  suppurative  inflammation,  and  perhaps 
necrosis,  wherever  they  lodge.  Thus,  even  capillary  emboli,  when 
infectious,  produce  abscesses.  The  multiple  abscesses  in  pysemia 
are,  for  the  most  part,  of  embolic  origin.  Bacteria  are  generally 
to  be  found  in  infectious  emboli,  and,  in  some  cases  at  least, 
constitute  the  poisonous  principle."     (Flint.) 

Embolism  in  the  brain  is  of  frequent  occurrence,  and  here  we 
have  to  deal  principally  with  its  results.  I  have  also  told  you 
that  the  embolus  is  generally  lodged,  for  obvious  anatomical  rea- 
sons, in  the  left  middle  cerebral  artery,  in  the  fissure  of  Sylvius, 
resulting  almost  inevitably  in  softening,  owing  to  the  non-estab- 
lishment of  the  collateral  circulation,  as  the  point  of  occlusion  is 
situated  above  the  circle  of  Willis.  We  have,  therefore,  no  hope 
of  recovery;  for,  should  the  patient  not  immediately  perish,  a 
hopeless  hemiplegia  will  be  the  consequence. 

There  is  a  very  important  matter  to  which  I  wish  once  more 
to  refer :  it  is  the  unfortunate  use  of  the  term  apoplexy  in  con- 
nection with  certain  symptoms  constituting  the  apoplectic  state. 
Apoplexy,  as  commonly  accepted,  designates  a  particular  condi- 
tion (cerebral  hemorrhage),  and  the  synonymous  use  of  the  word 
is  much  to  be  regretted. 

In  a  former  lecture,  when  speaking  to  you  of  the  apoplectic  form 
of  hypergemia  of  the  brain,  I  told  you  that  the  apoplectic  condi- 
tion is  common  to  many  different  diseases.  It  consists  in  sudden 
abolition  of  consciousness,  sensation,  and  voluntary  motion. 

This  condition  is  present  in  cerebral  hemorrhage ;  but  it  also 
exists  in  cases  of  epileptic  coma,  anaemic  coma,  ursemic  coma,  etc., 
and  in  fact  in  many  diseases  which  possess  very  different  patho- 
logical starting-points.  Therefore,  when  we  say  that  a  man  is  in 
an  apoplectic  condition,  we  do  not  necessarily  imply  that  he  has 
cerebral  hemorrhage. 

*  Charcot,  Localization  in  Diseases  of  the  Brain.     Italics  my  own. 


PAr.TIAL    AX^MIA    OF    THE   BRAIN.  77 

I  -vrill  add  that  this  apoplectic  state  not  onlv  always  exists 
during  the  initiatory  phenomena  of  cerebral  embolism,  but  also 
constitutes  a  marked  feature  of  the  disorder.  A  decided  ansemia 
will  occur  in  the  part  which,  by  the  obstruction  of  an  important 
artery,  is  suddenly  depriyed  of  a  large  amount  of  blood.  The 
consequence  of  this  shutting-oif  of  the  yascular  supply  has  already 
been  considered, — the  law  being  that  the  intensity  of  the  dis- 
turbances will  depend  upon  the  more  or  less  complete  occlusion 
of  the  arter}'. 

Hence,  should  the  ansemia  be  complete,  symptoms  of  depression 
alone  will  occur ;  if  incomplete,  we  will  obserye  an  alternation  of 
the  symptoms  of  excitation  with  those  of  depression. 

It  is  inyariably  of  great  importance  to  ascertain  what  disease 
has  occasioned  a  suddenly-developed  coma.  AYere  the  physician 
to  confine  his  diagnosis  to  ascertaining  the  presence  of  coma,  he 
would  only  expose  his  ignorance  of  the  fact  that  this  condition 
is  but  a  symptom,  and  not  a  disease,  and  no  more  to  be  treated 
regardless  of  its  pathological  causation  than  would  be  a  cough,  a 
feyer,  or  a  dyspnoea. 

The  apoplectic  condition  does  not  occur  in  thrombosis  unless 
the  latter  be  yery  extensiye ;  and  in  the  majority  of  instances 
thrombosis  is  so  gradual  that  the  apoplectic  phenomena  set  in 
only  towards  the  termination  of  life,  closing  the  scene.  The 
reverse  will  be  obseryed  in  embolism  :  the  same  symptoms  mani- 
festing themselves  ab  initio,  being,  in  truth,  the  first  signs  which 
attract  attention  and  cause  the  physician  to  be  summoned. 

The  first  knowledge,  then,  of  the  presence  of  embolism  proceeds 
from  the  apoplectic  state  which  overpowers  the  patient.  When 
these  apoplectic  phenomena  cease  (which,  however,  does  not  always 
happen),  what  will  be  the  condition  of  the  patient  ?  You  will 
find  a  well-marked  hemiplegia  of  the  right  side  of  the  body  (the 
embolism  being  generally  in  the  left  middle  cerebral  artery) ;  and 
the  reason  that  the  paralysis  is  situated  on  the  side  opposite  the 
one  affected,  is  that  the  lesion  is  located  above  the  point  of  decus- 
sation of  the  anterior  pyramids  of  the  medulla  oblongata. 

This  hemiplegia  is  almost  always  permanent.  Indeed,  I  have 
rarely  seen  or  read  of  an  instance  where  the  paralysis  completely 
disappeared  after  an  embolism ;  the  reason  of  this  being  that, 
when  once  plugged,  the  arter}-  is  closed  forever. 


78  DISEASES   OF  THE   NERVOUS  SYSTEM. 

A  cork  driven  into  the  neck  of  a  bottle  will  form  an  illustra- 
tion, with  this  difference  in  the  conditions :  that  in  the  case  of 
the  bottle  the  cork  may  be  removed,  but  the  embolus  cannot  be 
extracted  from  the  artery. 

It  may  be  that,  many  years  hence,  at  a  very  advanced  stage  of 
science,  there  will  be  discovered  certain  means  by  which  to  dis- 
lodge or  dissolve  the  pernicious  obstruction  :  this,  though  most 
improbable,  yve  will  not  deem  impossible, — agreeing  rather  with 
the  late  Dr.  Dunglison,  who,  after  a  long  and  rich  accumulation 
of  scientific  experience,  "  had  learned  never  to  use  the  word  im- 
possible." But,  to  return  to  the  subject,  the  patient,  should  he 
live  at  all,  will  remain  hemiplegic,  and  the  apoplectic  phenomena 
will  pass  off.  You  ask  me  why  the  consciousness  returns  whilst 
the  hemiplegia  persists.  Although  I  can  give  you  no  positive 
answer  to  this  question,  I  believe,  with  Niemeyer,  that  the  fol- 
lowing explanation  may  be  offered.  The  abolition  of  conscious- 
ness being  due  to  the  profound  anaemia  of  the  brain,  collateral 
hypersemia  and  resulting  oedema  follow,  intensifying  the  apo- 
plectic phenomena.  After  the  lapse  of  a  certain  period  of  time, 
say  a  few  days,  this  collateral  oedema  is  re-absorbed,  and,  conse- 
quently, the  apoplectic  state,  which  was  increased  by  the  oedema, 
rapidly  disappears ;  after  which  re-absorption,  the  pressure  which 
was  exerted  upon  the  cortical  cells  of  the  convolutions  of  the 
brain  is  also  relieved,  these  cells  once  more  developing  functions 
of  ideation  and  of  memory,  and  exhibiting  intellectual  activity 
and  consciousness. 

Another  important  fact  to  be  mentioned  in  this  connection  is 
that  collateral  oedema  following  embolism  is  a  condition  not 
necessarily  confined  to  the  brain.  Hence,  if  you  know  how  to 
apply  its  phenomena  to  this  organ,  you  will  not  be  at  a  loss  to 
apply  them  in  any  other  situation.  In  the  spleen,  or  the  liver,  or 
other  organs,  embolism  is  followed  by  collateral  cedema.  Why 
this  collateral  oedema  follows  embolism  we  do  not  positively 
know. 

You  will  now  ask,  how  is  it  that,  the  brain  being  a  dual  organ, 
one  part  should  be  rendered  inactive,  or  even  destroyed,  and  yet 
the  other  part  remain  without  function?  Why  might  not  the 
right  side  compensate  for  the  mischief  created  in  the  left  ?  The 
answer  is,  that  the  collateral  cedema  is  often  extensive,  and  its 


PARTIAL   ANEMIA   OF  THE   BRAIN.  79 

presence  excessively  deleterious,  exerting  more  or  less  pressure 
upon  the  other  hemisphere ;  and  although,  as  I  have  told  you, 
one  of  the  functions  of  the  falx  cerebri  is  to  prevent  this  encroach- 
ment, which  it  sometimes  does  successfully,  in  some  instances  it 
will  be  powerless  in  this  respect,  the  falx  then  dipping  over  to 
the  healthy  side.  The  pressure,  therefore,  being  transmitted,  the 
dual  action  will  be  interfered  with,  and  even  temporarily  abol- 
ished. It  has  been  observed  by  Niemeyer  that  the  posterior 
lobes  are  afforded  better  protection  "  against  a  pressure  acting  on 
the  opposite  hemisphere  than  the  frontal  lobes  are,  because  the 
falx  is  much  broader  posteriorly  and  hangs  much  farther  down 
than  it  does  anteriorly." 

We  have  still  another  important  fact  to  consider :  it  is  that 
we  often  have  coinoident  embolisms.  Of  course  it  must  be  only 
after  strong  presumptive  proof  that  you  diagnosticate  embolism ; 
but  if  you  want  confirmatory  evidence,  examine  the  peripheral 
arteries  that  are  easy  of  access,  and  you  may  sometimes  find  one 
or  several  of  them  obstructed.  This  fact  will  sometimes  prevent 
you  from  being  led  into  error.  Remember,  therefore,  that  coinci- 
dent embolism  may  or  may  not  be  present.  Coincident  embolism 
is  caused  when  the  clot  of  fibrin  constituting  the  embolus,  after 
becoming  detached,  separates  into  several  emboli,  which  are  carried 
by  the  circulation  into  different  arteries. 

After  having  attentively  listened  to  this  lecture,  you  may  still 
find  it  a  very  difficult  matter  to  distinguish  cerebral  hemorrhage 
from  cerebral  embolism  :  only  by  thoracic  exploration  can  you 
arrive  at  a  safe  conclusion.  Let  us  imagine  two  cases  both  at 
the  same  time  falling  into  the  apoplectic  state.  The  diagnosis 
will  be  based  upon:  1st,  a  history  of  the  cases;  2d,  the  exami- 
nation of  the  chest ;  3d,  the  sequence  of  events ;  4th,  the  age  of 
each  individual.  The  age  is  very  important,  for  we  know  that 
cerebral  hemorrhage  sometimes  results  from  atheromatous  arterial 
changes,  frequently  themselves  an  accompaniment  or  a  cause  of 
thrombosis,  which  is  a  disease  peculiar  to  old  persons.  Embo- 
lism, on  the  contrary,  occurs  at  all  ages,  irrespective  of  sex  or  of 
other  conditions  of  life.  Yet  in  some  instances  obscurity  exists, 
age  not  settling  the  question.  In  this  disease,  and  in  others, 
typical  cases  do  not  always  solve  the  problem.  It  is  known 
thai  even  children  are  occasionally  victims  of  cerebral  hemor- 


80  DISEASES    OF    THE   NERVOUS   SYSTEM. 

rhage.  The  rule,  however,  is  that  in  cerebral  hemorrhage  age 
has  great  significance, — the  disease  usually  affecting  persons  past 
the  meridian  of  life,  being  frequently  the  result  of  endo-arteritis 
deformans. 

We  may  now  sum  up  the  points  of  diagnostic  difference  be- 
tween thrombosis  and  embolism : 

THK0MB0SI3  EMBOLISM 

Is  generally  preceded  by  brain-symp-  Is    rarely   preceded    by   brain-symp- 

tomg.  toms. 

Symptoms  gradual.  Symptoms  sudden. 

No  rheumatic  bistory.  Oftentimes  rheumatic  history. 

Occurs  in  advanced  age.  Occurs  at  all  ages. 

Endo-arteritis  deformans  of  peripheral  Coincident  embolisms  are   sometinaes 

arteries  sometimes  occurs.  present. 

Apoplectic  phenomena  during  the  last  Apoplectic  phenomena  o2>  initio. 

stages. 

Is  always  formed  in  loco.  Proceeds  from  some  remote  point  of 

the  circulation. 

Never  take  any  one  sjonptom  as  a  positive  evidence  of  a  dis- 
ease. Do  not  confide  too  strongly  in  typical  descriptions.  I  have 
never  seen  a  case  of  essential  fever,  or  any  other  malady,  which 
strictly  corresponded  in  every  particular  with  the  classical  delinea- 
tions of  authorities.  You  must  rely  greatly  upon  the  care  you 
exercise  in  studying  disease,  and  upon  your  earnest  efforts  to 
diagnosticate  properly.  Do  not  essay  more  than  you  can  accom- 
plish, thereby  becoming  careless,  and  prescribing  for  various 
symptoms  without  arriving  at  their  proper  interpretation.  Exact 
diagnosis  underlies  all  rational  therapeutics. 

You  cannot  always  leave  the  bedside  perfectly  satisfied  that 
you  have  mastered  the  problem  of  your  patient's  ailment;  the 
most  accomplished  practitioner  sometimes  fails  to  ascertain  in 
one  visit  the  true  cause  of  a  malady,  and,  indeed,  several  visits 
may  be  made  before  certain  diseases  can  be  recognized,  if  recog- 
nized at  all.  Again,  I  am  satisfied  there  are  some  affections 
which  cannot  be  brought  under  any  nosological  arrangement. 
Hence  you  should  endeavor  to  become  good  diagnosticians,  and, 
when  you  are  unable  to  classify  a  disease,  should  apply  to  its 
treatment  the  principles  derived  from  your  general  pathological 
and  therapeutical  resources. 

Should  you  visit  a  patient  for  the  first  time  in  consultation 


PARTIAL    AXiEMIA   OF   THE    BRAIN.  81 

with  another  physician,  do  not  let  him  imbue  you  with  his  own 
ideas  before  making  an  examination  for  yourself,  or  you  will 
almost  certainly  be  biassed. 

I  feel  happy  to  state,  gentlemen,  that  these  views  of  ISTiemeyer 
as  to  the  pathological  anatomy  of  partial  cerebral  ana3mia,  which 
I  have  taught  to  successive  classes  for  over  twenty  years,  have 
recently  been  confirmed  by  Charcot. 

Charcot's  most  recent  "clinical  and  anatomico-patho- 
logical   RESEARCHES    UPON    CEREBRAL    SOFTENING   AND 

encephalitis."  * 

"Anatomical  study  of  cerebral  softening  in  old  men  has  led 
Charcot  to  affirm  the  correctness  of  the  doctrine  which  has  taught 
the  dependence  of  this  affection  upon  alterations  of  nutrition  due 
to  circulatory  disturbances,  and  this  equally  in  all  regions  of  the 
brain.  Modifications  of  the  cerebral  circulation  are  produced  by 
arterial  embolism,  atheroma,  arterial  thrombosis,  or  thrombosis 
of  the  cerebral  sinuses ;  and  in  all  cases  the  softening  is  the  result 
of  a  retrogressive  transformation  of  the  nervous  tissue ;  it  is 
emphatically  not  an  inflammatory  process." 

Although  the  consideration  of  encephalitis  must  be  postponed 
to  the  second  volume  of  these  Lectures,  I  desire  in  this  connection 
to  refer  to  certain  observations  of  Charcot,  which  are  intimately 
related  to  the  subject  of  cerebral  softening  and  encephalitis. 

Charcot  claims  that  "  in  encephalitis  the  anatomical  alterations 
are  primarily  due  to  a  proliferation  of  the  cellular  elements.  In 
softening,  the  granular  fatty  infiltration  of  the  cerebral  substance 
is  the  first  appreciable  lesion,  which  is  recognizable  twenty-four 
hours  after  the  vascular  obstruction.  Sometimes  the  elementary 
granules  are  found  isolated,  sometimes  in  round  masses,  consti- 
tuting a  variety  of  granular  corpuscles.  Hence  there  exists,  from 
an  anatomical  point  of  view,  a  fundamental  distinction  between 
cerebral  softening  and  encephalitis."  This  distinction  is  not  un- 
important from  a  clinical  stand-point.  It  is  corroborated  by  a 
great  number  of  observations  made  at  the  same  time  by  Vulpian 
and  Charcot, — namely,  that  certain  precursory  phenomena  of 
softening,  such  as  mental  confusion,  are  more  related  to  cerebral 

*  (Euvres  Completes,  1890. 
6 


82  DISEASES   OF  THE   NERVOUS   SYSTEM. 

ischsemia  than  to  cerebral  congestion,  and  that  certain  symptoms 
which  are  generally  ascribed  to  encephalitis,  such  as  delirium, 
convulsions,  contractures,  are  very  rare  as  initiatory  phenomena 
of  softening ;  when  observed  in  the  latter,  they  are  usually  to  be 
referred  to  some  complication.  Late  contractures,  so  frequently 
encountered  in  the  paralyzed  limbs  of  individuals  aifected  with 
old  softenings,  are  the  result  of  a  consecutive  lesion  of  the  spinal 
cord  (descending  sclerosis).  Charcot  concludes  his  remarks  on 
this  subject  by  citing  the  confirmatory  opinions  of  Messrs.  Pre- 
vost  and  Cotard,  also  referring  to  an  inaugural  thesis  of  M. 
Poumeau,  and  stating  that  M.  Proust  in  a  thesis  cites  some  facts 
relating  to  this  subject  communicated  by  M.  Charcot  to  him. 

Charcot  has  also  directed  attention  to  a  "  kind  of  softening,  not 
unusual,  which  occurs  in  the  cachexia  of  cancer  as  a  result  of 
arterial  thrombosis  from  inopexia." 

SYMPTOMATOLOGY   OF  ANEMIA   FROM   COLLATERAL   CEDEMA. 

How  may  we  recognize  anaemia  as  the  result  of  a  collateral 
oedema  in  the  brain  ?  In  order  to  do  this,  we  must  be  guided 
by  the  following  facts.  Whenever  we  have  a  partial  ansemia, 
the  result  of  a  collateral  oedema,  the  symptoms  of  one  will  be 
complicated  by  those  of  the  other.  We  have  seen  that  collateral 
oedema  is  sometimes  due  to  embolism  ;  yet,  again,  we  know  that 
hypersemia  of  the  brain  will  sometimes  have  the  same  effect.  In 
collateral  oedema  following  embolism,  a  capillary  ansemia  will  be 
produced,  which,  if  not  relieved,  may  terminate  fatally.  Further- 
more, when  a  collateral  oedema,  the  result  of  hypersemia  (which 
has  not  yet  resulted  in  permanent  partial  ansemia),  occurs,  we 
will  find  the  symptoms  of  collateral  oedema  accompanied  by  those 
of  the  primary  disease. 

All  the  pathological  variations  already  referred  to — partial 
hypersemia,  collateral  oedema,  partial  ansemia,  softening,  etc. — are 
produced  by  tumors,  clots,  abscesses,  or  anything  that  will  per- 
sistently encroach  upon  the  substance  of  the  brain  or  disturb  its 
circulation.  When  the  symptoms  of  intense  hypersemia  present 
themselves,  no  matter  by  what  cause  produced,  the  secondary 
phenomena  will  be  readily  understood,  and  the  ultimate  result 
may  be  softening  of  the  brain.  Now,  when  you  have  a  patient 
presenting  these  symptoms,  with  a  violent  collateral  oedema  of  the 


PARTIAL    AX^MIA    OF    THE    BRAEST.  83 

brain,  will  you  attack  that  cedema  with  diuretics,  or  absorbents, 
or  derivatives  ?  Most  assuredly  not ;  but  you  will  endeavor,  by 
directing  your  attention  to  the  'primary  affection,  to  relieve  the 
hyperemia,  by  which  you  may  prevent  softening.  In  other  words, 
treat  your  patient  anti-congestively,  so  to  speak,  and  you  will  at 
least  palliate,  should  you  not  cure,  the  disease.  But  if,  by  an 
unpardonable  oversight,  you  were  to  treat  certain  symptoms,  per- 
haps those  of  the  secondary  ansemia,  you  would  of  necessity  make 
matters  worse ;  for  you  would  thereby  intensify  the  hypersemia, 
and  a  hopeless  softening  would  surely  result.  You  therefore 
readily  understand,  and  of  course  appreciate,  the  necessity  of 
dwelling  upon  so  important  a  point.  Hence  remember  that, 
should  you  diagnosticate  a  secondary  anaemia  resulting  from  a 
previous  brain-disease,  or  from  anything  else  imaginable,  the 
symptoms  will  be  blended  with  those  of  the  primary  affection, 
whatever  that  may  be,  which  it  is  your  business  to  be  able  to 
recognize  and  to  treat  accordingly. 

This  collateral  cedema  enables  us  to  explain  several  obscure 
forms  of  morbid  manifestations ;  for  instance,  it  must  have  oc- 
curred to  those  of  you  who  have  witnessed  post-mortem  exami- 
nations that  the  appearance  of  the  brain  is  sometimes  cj^uite 
different  from  what  we  expected  to  find,  judging  from  the  symp- 
toms present  during  life. 

Let  us  suppose,  for  example,  that  you  have  a  patient  suffering 
from  hemiplegia-,  a  paralysis  either  of  motion  or  of  sensation,  or  of 
both,  with  or  without  spasms,  etc.  After  death  you  examine  the 
encephalon,  and  all  you  find  may  be  a  small  clot  lying  upon  the 
superior  part  of  the  periphery  of  the  brain  and  not  necessarily  in 
the  motor  tract,  or  a  disease  Avhich  does  not  encroach  on  the 
cranial  cavity.  Now,  how  will  you  proceed  to  explain  that  a 
very  small  clot,  situated  upon  the  surface  of  one  of  the  con- 
volutions of  the  brain,  may  under  these  circumstances  produce 
paralysis?  You  will  answer,  by  the  pressure  the  clot  exercised 
upon  the  convolutions,  which  pressure  is  transmitted  to  the 
medullary  fibres,  and  finally  to  the  corpus  striatum,  or  even  to 
more  distant  parts  at  the  base  of  the  brain.  Such,  however, 
would  be  an  incorrect  conclusion ;  for,  if  you  recall  what  I  have 
already  stated,  you  will  remember  that  the  brain  is  incompressible. 

You  have  not,  I  am  sure,  forgotten  the  explanation  of  Niemeyer, 


84  DISEASES   OF   THE   NERVOUS   SYSTEM. 

that  a  disturbance  so  situated  may  produce  an  irritation,  in  the 
neighborhood  of  which  you  may  have  a  hypersemia,  •  and,  as  a 
result  of  this,  a  collateral  oedema,  and  finally  ansemia;  and  if 
this  collateral  oedema  dip  deeply  into  the  substance  of  the  brain, 
and  the  transuded  serum  press  upon  the  corpus  striatum  or  internal 
capsule,  a  paralysis  may  be  the  result. 

In  this  manner,  then,  are  we  enabled  to  explain  how  a  minute 
clot  upon  the  periphery  of  the  brain  may  produce  paralysis ;  and 
in  proportion  as  the  peripheral  clot  becomes  absorbed,  the  result- 
ing hypersemia  will  be  removed,  the  collateral  oedema  disappear, 
and  the  symptoms  of  paralysis  slowly  and  gradually  pass  away. 

In  addition  to  the  foregoing,  we  have  symptoms  of  other  dis- 
eases, which  can  be  explained  only  by  the  pressure  of  collateral 
oedema.  For  instance,  the  cerebellum  may  be  partly  destroyed 
without  any  peculiar  symptoms  necessarily  revealing  the  fact 
during  the  life  of  the  patient.  (It  has  been  contended  by  emi- 
nent physiologists  that  the  cerebellum  is  the  seat  of  the  power 
of  co-ordination ;  but  this  I  am  by  no  means  disposed  to  admit.) 
On  the  other  hand,  it  happens  that  some  of  the  most  serious 
symptoms,  such  as  hemiplegia,  sometimes  coexist  with  the  above 
lesion. 

How  are  we  to  understand  such  paradoxical  conditions  ?  How 
shall  we  explain  these  seeming  contradictions  ?  The  enigma  is 
solved  when  we  recollect  that  we  may  have  a  collateral  hypersemia 
extending  upward  towards  the  brain,  and  followed  by  a  collateral 
oedema.  In  the  former  case,  a  hemiplegia  would  be  explained. 
The  hypersemia  may  extend  towards  the  corpora  quadrigemina  by 
the  superior  peduncles  of  the  cerebellum,  the  processus  e  cerebello 
ad  testes;  or  it  may  be  conducted  along  the  middle  peduncles, 
reaching  the  pons  Varolii  or  the  tuber  annulare  ;  or,  again,  it  may 
travel  along  the  inferior  peduncles  to  the  restiform  bodies,  pro- 
ducing, in  each  case,  corresponding  phenomena,  which  may  exist 
separately  or  conjointly,  causing  the  most  serious  and  complicated 
results. 

We  have  but  one  more  form  of  symptoms  to  consider  in  con- 
nection with  ansemia  of  the  brain :  any  force  or  foreign  body  or 
any  imaginable  pathological  condition  that  will  in  any  way  en- 
croach upon  either  hemisphere  or  the  cerebellum  may  produce 
disturbances  of  the  circulation,  and  result  in  paralysis,  hemiplegia. 


PARTIAL   ANiEMIA   OF   THE   BRAIN.  85 

softening,  etc.  Should  the  pressure  be  on  one  side,  we  will  usually 
have  a  hemiplegia  of  the  opposite  side  of  the  body.  Should  a 
tumor  or  an  abscess  be  present,  the  paralytic  phenomena  will 
probably  be  slowly  produced,  because  there  will  be  sufficient  time 
for  a  gradual  atrophy  of  the  brain  to  prevent  great  encroachment 
on  the  surrounding  mass  on  the  part  of  these  adventitious  prod- 
ucts. But  the  medullary  masses  of  one  hemisphere  may  be  dis- 
eased and  softened  by  tumors,  abscesses,  etc.,  and  still  no  marked 
symptoms  necessarily  result.  This  is  due  to  the  comparative  non- 
importance  of  the  former  and  to  the  compensatory  agtion  of  the 
opposite  hemisphere,  and  to  the  growth  of  the  latter  having  been 
very  slow,  with  a  corresponding  absorption  of  brain-substance  as 
it  became  replaced  by  the  intruding  body.  But  in  anaemia,  which 
occurs  when  the  tumor,  etc.,  develops  rapidly,  in  proportion  to 
the  amount  of  destruction  of  the  nerve-cells,  you  will  find  symp- 
toms of  depression  speedily  developed  and  brain-disturbances  of 
a  paralytic  character.  It  is  important  to  remember  that  these 
phenomena  will  depend  greatly  upon  the  situation  of  the  parts 
involved.  Were  there  no  perplexing  difficulties  in  the  recogni- 
tion of  symptoms  peculiar  to  diseases  of  the  brain,  their  study 
might  become  more  satisfactory.  Experience  teaches  us  that  the 
diagnosis  of  all  brain-maladies  is  quite  obscure.  There  is  one 
condition,  however,  the  symptoms  of  which  are,  according  to 
Niemeyer,  unmistakable,  almost  pathognomonic,  so  that  we  are 
enabled  to  diagnosticate  it  quite  accurately.  I  allude  to  an  cw- 
croachment  of  some  kind  upon  the  posterior  cranial  fossa,  that 
part  which  lies  beneath  the  tentorium  cerebelli.  The  symptoms 
attending  diseases  of  the  posterior  cranial  fossa  are :  1st,  pains 
in  the  occipital  region ;  2d,  vomiting ;  3d,  a  morbid  impairment 
of  sensibility  (incomplete  anaesthesia) ;  4th,  a  peculiar  develop- 
ment of  partial  paralyses ;  5th,  dysphagia  and  impaired  articu- 
lation ;  and  6th,  dizziness  possessing  certain  distinctive  peculiarities. 
We  all  know  that  dizziness  may  be  the  result  of  an  indigestion, 
or  of  an  over-indulgence  in  fermented  or  distilled  liquors,  or  may 
proceed  from  various  causes  existing  wherever  vertigo  is  present, 
whether  originating  in  the  stomach,  brain,  or  other  part.  But 
in  these  last-mentioned  cases  the  dizziness  is  always  subjective, 
being  a  hallucination,  —  patients  imagining  that  surrounding 
objects   are   continually  whirling   around   them.      Whether   the 


86  DISEASES   OF   THE  NEEVOUS   SYSTEM. 

patient  is  lying  down,  standing  erect,  or  walking,  the  dizziness 
will  continue  without  interruption ;  while,  on  the  other  hand,  in 
diseases  contracting  the  space  in  the  posterior  cranial  fossa  this 
dizziness  exists  only  when  the  patient  is  walking,  moving,  or  in  the 
erect  postwre,  and  immediately  disappears  on  his  lying  down. 

After  this  dissertation  upon  partial  ansemia,  you  would  un- 
doubtedly like  to  be  compensated  with  practical  observations 
regarding  *the  best  modes  of  its  treatment,  and  a  careful  com-^ 
parison  of  their  relative  values.  In  this  respect  I  must  disap- 
point you,  for  the  most  I  can  say  is,  that  the  less  you  actively 
interfere,  the  better!  Thrombi  and  emboli,  you  are  aware,  can- 
not be  mechanically  removed ;  nor  have  we  any  therapeutical 
resources  at  our  command  with  which  to  attain  such  an  end. 
Several  things — stimulants,  for  instance — have  been  recommended, 
but  they  are  all  useless ;  for  they  can  never  unplug  an  artery. 
Nevertheless,  you  must  not  fail  to  resort  to  the  best  hygienic 
treatment  possible,  using  tonics  to  counteract  loss  of  vigor.  You 
may  also  treat  symptoms  as  they  arise,  and,  above  all,  must 
endeavor  to  obviate  collateral  hyperemia. 

Although  a  part  of  your  patient's  brain  may  be  anaemic,  death 
from  a  collateral  hypersemia  may  occur.  Should  the  symptoms 
of  depression,  which  always  exist  in  profound  ansemia,  be  com- 
plicated by  alarming  symptoms  of  irritation,  beware  of  collateral 
hypersemia,  and  treat  your  patient  accordingly,  blistering,  leech- 
ing, purging,  etc., — with  due  caution,  however, — and  you  will 
at  least  succeed  in  averting  an  immediate  and  perhaps  transitory 
danger. 


LECTURE   ly. 

GENERAIi   CEREBRAL,   ANEMIA. 

Symptoms — Diagnosis — Treatment. 

Gentlemen, — In  order  more  fully  to  understand  the  physi- 
ology of  cerebral  ansemia,  let  us  for  a  moment  consider  the 
requirements  of  the  nervous  system  and  the  conditions  of  its 
normal  excitability.     They  are  : 

1.  Constitutional  integrity  of  nerve-substance. 

2.  Normal  circulation  of  the  blood. 

3.  Normal  composition  of  the  blood. 

4.  Alternations  of  rest  and  activity.     (Jaccoud.) 

To  these  we  may  add  a  normal  temperature  of  the  blood  and 
perfect  vascular  integrity. 

At  this  juncture  it  is  well  to  recall  what  has  been  said  in  a 
preceding  lecture,  that  the  symptomatic  phenomena  of  cerebral 
hyperemia  and  anaemia  do  not  in  any  respect  differ  from  one 
another,  if  the  symptoms  alone  are  considered. 

It  is  well  to  bear  in  mind  that  cerebral  ansemia,  when  the 
quality  of  the  blood  is  impaired,  is  always  of  gradual  occurrence, 
and  affects  the  entire  brain,  but  when  the  quantity  of  blood  of  the 
whole  brain  is  deficient  its  abstraction  may  be  either  sudden  or 
gradual. 

Pressure  on  the  blood-vessels  going  to  the  head,  and  aortic 
aneurisms,  are  sometimes  the  causes  of  diminished  blood-supply 
to  the  brain. 

The  operation  of  paracentesis  abdominis  may  sometimes  pro- 
duce a  comparatively  bloodless  condition  of  the  brain,  which  may 
terminate  fatally.  Associated  with  this  there  is  often  an  unequal 
distribution  of  blood,  which  peculiarly  leads  to  a  dilatation  of 
the  intestinal  vessels  when  dropsical  accumulations  are  suddenly 
removed. 

Spasm  of  the  blood-vessels  of  the  brain  with  accompanying 

87 


88  DISEASES  OF  THE  NEEVOUS  SYSTEM. 

narrowing  of  their  calibre,  produced  by  various  causes,  is  a 
well-known  factor  in  the  production  of  sudden  and  transitory 
anaemia,  exemplified  in  the  intense  cerebral  anaemia  superinduced 
by  capillary  contraction  during  the  initiatory  phenomena  of 
epilepsy. 

Pathological  conditions  of  imperfect  blood-renewal  play  a 
prominent  role  in  the  production  of  cerebral  anaemia. 

Fevers  have  most  pernicious  effects  on  the  constitution  of  the 
blood,  and  develop  and  intensify  anaemia  by  tissue-oxidation  and 
corresponding  retrograde  metamorphosis,  to  say  nothing  of  the 
retention  of  effete  or  excrementitious  material  in  the  circulation. 

These  pernicious  results  and  qualitative  perversions  of  fevers, 
inflammations,  and  other  acute  maladies  upon  the  blood  are 
familiarly  evinced  during  convalescence  from  protracted  disease, 
and  by  the  "  delirium  of  inanition,"  described  by  Dr.  Clymer  so 
graphically  in  Aitken's  Practice. 

General  cerebral  anaemia  most  frequently  originates  in  causes 
not  restricted  in  character,  but  which  are  expressive  of  particular 
states  of  the  system  at  large.  All  hemorrhages,  excessive  or  col- 
liquative discharges,  whether  menstrual,  intestinal,  hemorrhoidal, 
uterine,  suppurative,  or  exudative,  but  especially  the  first  men- 
tioned, which  are  by  far  the  most  common,  must  sooner  or  later 
induce  an  anaemia,  more  or  less  profound,  from  which  the  brain 
will  suffer,  entailing  thereby  a  disordered  and  imperfect  perform- 
ance of  its  functions.  The  physiological  law  already  referred  to 
must  not,  in  this  connection,  be  lost  sight  of.  If  the  cause  capable 
of  resulting  in  abolition  of  the  nervous  excitability  be  not  sufii- 
cient  to  do  so  at  the  commencement,  its  partial  effect  will  invari- 
ably be  a  precedent  condition  of  exaggerated  Junctional  activity. 
This  furnishes  an  explanation  of  many  of  the  phenomena  of  cere- 
bral anaemia,  and  offers  the  only  rational  interpretation  of  the 
commingling  of  the  symptoms  of  irritation  with  those  of  depression 
which  is  common  to  this  disease,  and  which  leads  inexperienced 
physicians  to  suppose  that  they  are  dealing  with  congestion,  which 
they  treat  actively  and  with  disastrous  results,  while,  in  reality, 
anaemia,  more  or  less  profound,  lies  at  the  bottom  of  the  diffi- 
culty. The  hydrocephaloid  of  3Iarshall  Hall  exemplifies  what 
we  desire  to  designate  as  a  common  source  of  error  in  this  respect, 
its  etiology  being  frequently  misunderstood,  while  therapeutic  re- 


GENERAL   CEREBRAL   ANEMIA.  89 

sources  directed  to  its  relief,  from  their  inappropriateness,  often 
increase  the  evil  they  are  intended  to  avert. 

In  cases  where  cerebral  ansemia  is  very  gradually  produced, 
an  exaggeration  of  the  excitability  of  the  brain  will  result  in 
what  Gowers  calls  "  irritable  weakness."  The  cerebral  activities 
will  then  be  excited  with  abnormal  facility.  Convulsions  them- 
selves are  no  indication  of  a  different  pathological  condition : 
indeed,  as  Gowers  adds,  "  that  the  nerve-cells  should  '  discharge' 
when  the  blood-supply  is  arrested  is  a  fact  of  very  great  physio- 
logical interest  as  an  indication  of  the  reserve  of  force  that  must 
be  stored  up  in  the  nerve-cells,  and  of  the  probability  that  sudden 
overaction  is  due  to  diminution  of  resistance  to  action,  and  not  to 
an  increase  in  the  force-generating  function  of  the  cell.^  Latent 
energy  may  be  liberated,  but  new  force  can  scarcely  be  produced 
under  the  influence  of  sudden  anaemia." 

It  must  be  remembered  that  ansemia  during  life  is  not  proved 
by  the  mere  pallor  of  the  brain  as  observed  on  autopsy,  as  the 
modes  of  death  greatly  influence  the  amount  of  blood  found  in 
the  brain  in  post-mortem  examinations. 

In  diffused  cerebral  ansemia  much  cerebro-spinal  fluid  is  often 
present,  and  alters  the  appearance  of  the  nerve-cells,  and  not  in- 
frequently develops  many  of  the  conditions  which  we  found  exist- 
ing when  describing  the  anatomical  appearances  of  collateral 
cedema.  If  these  conditions  persist,  irreparable  damage  may  be 
done  to  the  nutrition  of  the  brain. 

Quantitative  and  qualitative  blood-changes  will  more  or  less 
materially  influence  the  production  of  cerebral  ansemia,  especially 
when,  from  chylopoietic  disease,  systemic  conditions,  or  the  dif- 
ferent dyscrasise,  improper  or  deficient  hsematosis  results.  The 
absence  of  properly  arterialized  blood — its  presence  being  a  sine 
qua  non  for  the  due  performance  of  the  cerebral  functions — will 
be  readily  appreciated. 

It  follows,  from  what  we  have  said,  that  ansemia  is  produced 
whenever  the  brain  receives  an  insufficient  quantity  of  blood, 
whether  this  be  due  to  arterial  obstruction  or  to  reduction  of 
the  volume  of  this  fluid.  Moreover,  the  oxygen  of  the  vital 
current,  being  an  essential  agent,  must  not  be  unduly  diminished, 

*  Italics  in  this  quotation  are  my  own. 


90  DISEASES   OF   THE   NERVOUS   SYSTEM. 

for  the  proper  nutritive  processes  would  not  be  accomplished,  and 
the  normal  performance  of  their  functional  activities  would  be 
prevented.  The  red  corpuscles  being  "carriers  of  oxygen,"  a 
deficiency  on  their  part,  so  far  as  the  brain  is  concerned,  would 
be  equivalent  to  inadequacy  of  the  blood  itself.  Jaccoud  and 
Niemeyer  mention,  among  the  causes  of  general  cerebral  anaemia, 
those  of  vascular  origin,  often  reflex  in  character,  produced  by 
unusual  mental  emotions,  eventuating  in  a  contraction  of  the  cere- 
bral vessels.  In  these  cases,  loss  of  consciousness  and  sudden 
pallor  of  the  countenance  constitute  the  prominent  symptoms. 

Mechanical  causes  are  also  cited,  as  in  instances  where  an  undue 
amount  of  blood  is  retained  in  other  organs  at  the  expense  of  the 
general  circulation.  It  is  a  well-known  fact  that  syncope  is  fre- 
quently caused  by  moving  patients  ill  with  fever,  or  by  patients 
assuming  too  soon  the  erect  posture  while  convalescing  from  pro- 
tracted and  exhausting  affections.  Dr.  Todd,  in  his  work  upon 
Acute  Diseases,  particularly  insists  upon  the  serious  dangers  at- 
tendant upon  exertion  in  both  instances.  The  hazard  is  enhanced 
by  a  combination  of  such  causes  as  an  enfeebled  cardiac  impulse 
and  the  sudden  accumulation  of  blood  in  the  lower  extremities. 

The  symptoms  will  vary,  according  to  the  slow  or  rapid  devel- 
opment of  the  anaemia.  In  the  latter  instance,  syncope — perhaps 
accompanied  by  convulsions,  if  the  ansemia  be  intense — may  be 
anticipated.  In  cases  of  slowly-produced  and  more  permanent 
cerebral  anaemia,  the  symptoms  of  irritation  will  be  more  or  less 
prominent.  In  graver  conditions  of  this  pathological  state, 
marked  symptoms  of  depression  will  succeed  those  of  excitation, 
which  are  merely  temporary  and  initiatory.  These  latter  will  so 
closely  resemble  the  phenomena  presented  by  cerebral  hypersemia 
as  to  be  inseparable  in  description;  while  the  former  will  be 
more  particularly  distinguished  by  such  expressions  as  "  syncope" 
and  "  physical  and  intellectual  apathy." 

DIAGNOSIS. 

The  symptomatic  manifestations  of  hypercemia  and  ancemia  are 
identical,  and,  furnish  no  clue  by  which  we  can  recognize  and  dif- 
ferentiate these  two  conditions  of  diametrically  opposite  pathological 
character.  Maudsley  says  that  "  since  the  time  of  Hippocrates  it 
has  been  known  that  when  there  is  too  little  blood  in  the  brain, 


GENERAL   CEREBRAL   AN^MLA..  91 

symptoms  are  exhibited  similar  to  those  which  are  produced  by 
a  congestion  of  blood :  pains  and  swimming  in  the  head,  con- 
fusion and  incapacity  of  thought,  affections  of  the  senses  and  of 
movement,  occur  in  consequence  of  ansemia  of  the  brain  as  cer- 
tainly as  they  do  in  consequence  of  congestion.  In  both  cases  the 
due  nutrition  of  the  nerve-cell,  which  is  the  agent  of  cerebral 
function,  is  greatly  hindered  ;  and  much  of  the  ill  eifect  is  similar, 
though  the  causes  appear  to  be  so  different.  In  reality,  however, 
the  causes  are  not  so  different  when  we  proceed  to  analyze  the 
conditions  comprised  under  the  terms  anaemia  and  congestion.  In 
that  continued  relation  between  the  organic  element  and  the  blood 
by  which  the  due  reparative  material  is  brought  and  waste  matter 
carried  away,  it  amounts  to  much  the  same  thing  whether  through 
stasis  of  the  blood  the  refuse  is  not  carried  off  and  reparative 
material  brought  to  the  spot  where  it  is  wanted,  or  whether  the 
like  result  ensues  by  reason  of  a  defective  blood  and  deficient 
circulation ;  it  is  little  matter  to  the  inhabitants  whether  the  street 
is  almost  blocked,  or  whether  its  entrance  is  almost  closed,  so  long 
as  free  circulation  is  prevented."  The  history  of  the  case,  con- 
comitant symptoms,  and  general  condition  of  the  patient's  system 
will  therefore  furnish  the  only  reliable  data  upon  which  to  base 
our  conclusions,  which  would  necessarily  be  erroneous  were  we 
to  rely  exclusively  upon  the  cerebral  symptoms,  or  even  attach 
undue  importance  to  the  appearance  of  the  patient ;  having  before 
stated  that  pallor  may  coexist  with  profound  and  dangerous  hy- 
peremia, thus  constituting  a  source  of  fallacy  not  to  be  forgotten. 
The  clinical,  pathological,  and  therapeutical  antecedents  must, 
therefore,  be  carefully  studied.  I  can  recall  a  case  in  reference  to 
which  I  was  for  a  few  days  in  doubt,  but  finally  diagnosticated 
cerebral  anaemia,  because  the  lady  was  greatly  relieved  when,  in 
lowering  her  head,  she  favored  the  gravitation  of  the  blood  to 
her  brain,  and  all  her  symptoms  became  remarkably  exaggerated 
when  in  the  erect  posture.  You  who  were  with  us  last  winter 
will  recollect  the  successful  issue  of  a  case  which  I  diagnosticated 
to  be  general  cerebral  anaemia,  at  the  hospital,  the  result  of  a  pro- 
fuse hemorrhoidal  flow,  accompanied  by  epistaxis,  which  rapidly 
yielded  to  iron,  digitalis,  and  a  liberal  administration  of  nutrients. 
Yet,  owing  to  some  striking  symptoms  of  excitement,  the  case  had 
previously  been  treated  by  several  experienced  physicians  by  spo- 


92  DISEASES  OF   THE   NEEVOUS  SYSTEM. 

liative  measures,  on  the  supposition  of  intense  cerebral  hypersemia 
existing,  with  the  result,  I  need  hardly  add,  of  greatly  aggravating 
all  the  symptoms,  and  endangering  the  patient's  life.  Cardiac 
examination  must  never  be  neglected  in  doubtful  cases,  as  an  en- 
feeblement  of  the  first  sound  or  a  diminished  impulse,  especially 
if  accompanied  by  blood-murmurs,  would  have  the  utmost  signifi- 
cance. 

All  conditions  of  anaemia  are  exaggerated  in  the  erect  posture. 
"  It  has  been  remarked  that  some  anaemic  persons  can  think  well 
only  when  lying  down."     (Gowers.) 

The  mode  of  meeting  the  indications  of  a  cerebral  anaemia  re- 
sulting from  a  sudden  and  profuse  loss  of  blood  resolves  itself 
into  the  usual  modes  of  relieving  syncope.  Position,  arterial  com- 
pression, even  the  temporary  application  of  the  tourniquet  upon 
the  principal  superficial  arteries,  Nekton's  method  used  in  chloro- 
form narcosis,  consisting  in  holding  for  a  long  period  the  lower 
extremities  high  above  the  patient's  head,  the  preparations  of 
ammonia,  ether,  and  brandy,  internally  administered  (or  the  two 
latter  hypodermically  given),  and,  in  very  critical  cases,  trans- 
fusion, should  all  be  judiciously  essayed.  In  cases  of  habitual 
anaemia,  arsenic,  chalybeate  preparations,*  the  improvement  of 
the  nutritive  functions,  an  easily-digested  and  liberal  dietary  scale, 
especially  of  milk  and  highly-nitrogenized  substances,  and  the 
removal  of  the  cause  of  the  pathological  condition,  where  possible, 
are  resources  of  the  greatest  value,  and  will  often  be  rewarded 
with  success. 

In  conclusion,  I  would  particularly  admonish  you,  gentlemen, 
to  bear  in  mind  the  dangers  of  hydroeephaloid  disease  in  young 
children.  Treat  their  diarrhoeas — a  fruitful  source  of  this  affec- 
tion— early  and  earnestly.  Do  not  refrain  from  arresting  the  in- 
testinal discharge  for  fear  of  producing  brain-symptoms,  as  is  too 
often  done,  in  compliance  with  a  maternal  prejudice,  fraught  with 
danger  to  the  little  ones.  Recollect,  as  Trousseau  says,  "  that  the 
continuance  of  diarrhoea  in  teething  children  predisposes  to  con- 
vulsions." Do  not  be  deluded  by  the  supervention  of  the  symp- 
toms of  irritation  in  children  who  have  experienced  colliquative 

*  My  experience  has  conclusively  proved  that  the  salts  of  manganese  are 
often  advantageous  when  combined  with,  or  even  substituted  for,  those  of  iron. 


GENERAL   CEREBRAL   ANEMIA.  93 

discharges,  notwithstanding  the  flushed  face,  heated  skin,  general 
restlessness,  twitching,  insomnia,  and  even  convulsions.  In  such 
subjects,  resort  to  stimulants  and  mjlk,  and,  in  older  children, 
to  the  famous  "  raw  meat  diet."  You  will  thereby  prevent  the 
subsequent  stage  of  collapse,  when  the  vital  powers  will  be  too 
prostrated  to  admit  of  recuperation. 

Forewarned,  you  should  be  forearmed ;  and  it  will  henceforth 
be  inexcusable  in  you  to  commit  such  a  blunder  as  to  treat  similar 
cases  by  spoliative  measures.  Resist  all  temptations  to  be  misled 
by  the  threatening  aspect  of  the  initiatory  symptoms,  so  deceptive 
as  to  compel  you  to  select  therapeutic  means  which  would  in- 
evitably result  fatally,  consigning  to  a  premature  grave  the  little 
sufferer  committed  to  your  care ;  which  catastrophe,  instead  of 
being  averted,  would  be  precipitated  by  an  ignorance  as  unpardon- 
able as  unjustifiable. 

An  elegant  formula  for  the  administration  of  manganese  is  that 
of  Wyeth's  "  compound  syrup  of  the  phosphate  of  manganese," 
which  also  contains  phosphate  of  iron,  the  dose  being  a  teaspoon- 
ful  three  times  a  day  after  meals,  to  which  two  or  three  minims 
of  Fowler's  solution  of  arsenic  to  each  dose  may  be  added  in  ap- 
propriate cases.  When  it  is  desirable  to  administer  a  preparation 
of  iron  which  does  not  constipate,  the  following  formula  will  be 
found  excellent : 

R   Tinct.  ferri  chlor.,  f^^iii ; 
Liq.  amnion,  acetatis,  fgi; 
Acidi  acetici  dil.,  f^ii ; 
Syrupi  zingiberis,  ad  f^iv. — M. 
S. — Two  teaspoonfuls  ter  die  after  meals,  in  water. 

In  cases  where  there  is  a  malarial  complication  the  following 
pill  will  be  found  valuable  : 

R   Quin.  bisulph.,  gr.  c  vel  31 ; 

Ext.  nucis  vom.,  gr.  vii ; 

Acidi  arseniosi,  gr.  i ; 

Pilulse  ferri  carb.,  ^i. 
M.  et  ft.  pilulae  no.  xx. 
S. — One  ter  die  after  meals. 

The  amount  of  quinine  above  recommended  can  be  varied,  so  as 
to  make  each  pill  contain  either  three  or  five  grains  of  quinine. 


94  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Another  very  powerful  tonic  pill  which  I  use  in  many  of  these 
cases  is  composed  as  follows  : 

R   StrycliniiiEe  sulph., 

Acidi  arseniosi,  aa  gr.  iv  ; 

Ferri  sulph.  exsiccat. ,  gr,  c ; 

Quininse  sulph.,  gr.  c; 

Ext.  digitalis,  gr.  xvi. 
M.  et  div.  in  pilulas  no.  c. 
S. — One  pill  three  times  daily  after  meals. 

A  pill  which  I  originated  many  years  ago,  and  which  has 
been  thoroughly  tested,  having  indeed  proved  invaluable  in  many 
cases,  especially  in  general  anaemia,  chlorosis,  hysteria,  melan- 
cholia, hypochondriasis,  and  neurasthenia,  is  composed  as  foUoAvs  : 

R   Auri  et  sodii  chlor. ,  gr.  v  ; 

Stryclminffi  sulph.,  gr.  iiss  ; 

Ferri  arsen.,  gr.  xvif  ; 

Quininee  sulph.,  gr.  c. 
M.  et  div.  in  pilulas  no.  c. 
S. — One  ter  die  after  meals. 

Most  of  these  pills  are  made  for  me  by  McKesson  &  Rob- 
bins,  of  Xew  York  City,  and  Sharpe  &  Doane,  of  Baltimore.  I 
often  add  to  this  treatment  the  various  preparations  of  maltine 
made  by  the  Maltine  ]\Ianufacturing  Co.,  of  jS^ew  York.  I  have 
for  years  used  the  latter  as  a  more  easily  assimilated  nutritive 
agent  than  cod-liver  oil ;  the  last-named  article  I  prefer  to  give 
in  emulsion  : 

R   01.  morrhuffi  opt.,  fgvi ; 
Pulv.  acacise,  _^vi ; 
Aq.  destil.,  f§ii  ; 
Glycerol,  hypophosph., 
Syrupi  calcis  lactophosph.,  aa  f^iv; 
01.  gaultherise,  TT\,xx. — M. 
S. — One  tablespoonful  three  times  daily  after  meals. 

I  often  use  modifications  of  what  I  call  "  nerve-food"  in  cases 
of  antemia  and  neurasthenia.  One  of  the  combinations  of  this 
character  that  I  most  frequently  use  is  composed  of  equal  parts 
of  glycerole  of  the  hypophosphites  and  syrup  of  the  lactophos- 
phate  of  lime,  the  dose  of  which  would  be  two  teaspoonfuls  before 
meals.     I  varv  this  sometimes  as  follows  : 


GENERAL   CEREBRAL,   ANiEMIA.  95 

B   Syrupi  calcis  lactophospli., 

Glycerol,  hypophosph., 

{Fairchild's)  Ess.  pepsin,  vel  elix.  peptonoids, 

Elix.  calisayae,  tu'i  f^i. — M. 
S. — One  tablespoonful  ter  die  before  meals. 

I  find  the  addition  of  pepsin  to  this  combination  valuable 
where  gastric  disturbances  exist. 

Phosphorus  may  also  be  administered,  in  pills  of  phosphide 
of  zinc  and  extract  of  nux  vomica,  as  recommended  by  Ham- 
mond,— viz.  : 

R   Zinci  phosphidi,  gr.  iii ; 
Ext.  nucis  vom.,  gr.  x. 
M.  et  ft.  in  pil.  no.  xxx. 
S. — One  ter  die. 

I  sometimes  use  phosphorus  in  the  form  of  Thompson's  solu- 
tion, as  recommended  by  Seguin.  However,  this  preparation  is 
an  exceedingly  strong  one,  and  is  more  applicable  to  intractable 
cases  of  neuralgia.  I  agree  with  Hammond  that  nitrite  of  amyl 
by  inhalation  is  highly  beneficial  in  cerebral  anaemia,  although  I 
believe  the  most  useful  application  of  this  remedy  is  to  abort  the 
aura  epileptica.  I  will,  however,  refer  more  particularly  to  the 
uses  of  nitrite  of  amyl  and  Thompson's  solution  of  phosphorus 
in  my  lectures  on  epilepsy  and  neuralgia. 

"Whilst  alcohol  and  opium  constitute  powerful  remedial  agents 
in  treating  all  cases  of  anaemia,  I  emphatically  protest  against 
their  careless  and  indiscriminate  administration.  I  have  for  years 
taught  my  students  that  there  is  a  great  responsibility  in  resorting 
to  them  in  all  chronic  cases,  as  their  improper  and  habitual  use 
but  too  frequently  morally  wrecks  the  patient,  who  thus  becomes  the 
innocent  victim  of  professional  carelessness.  In  fact,  a  maxim  with 
which  I  permit  no  compromise  interdicts  the  use  of  opium  and 
all  its  preparations,  and  of  all  vinous,  malt,  and  alcoholic  stimu- 
lants, in  chronic  diseases.  Physicians  cannot  be  too  strenuously 
warned  in  this  direction.  I  know  but  one  exception  to  this  rule, 
which  is  the  classic  use  of  opium  in  melancholia :  under  these 
circumstances  patients  should  be  kept  ignorant  of  the  nature 
of  the  drug  they  are  taking,  and  the  prescription  should  not  be 
renewable  without  the  express  permission  of  the  physician. 

In  all  cases  where  diet  is  an  important  adjunct  of  treatment, 


96  DISEASES   OF   THE   NERVOUS   SYSTEM. 

a  distinct  diet-list  should  be  furnished  to  the  patient,  who  should 
be  allowed  no  discretion  in  this  matter.  Just  as  there  exists  a 
dosage  in  electricity,  there  should  be  correspondingly  one  of  exer- 
cise, and  a  dosage,  as  well  as  scientific  regulation,  in  matters  of 
diet. 

Where  the  patient  is  much  prostrated,  neurasthenic,  and  suffer- 
ing from  a  want  of  muscular  tone,  I  have  found  the  following 
prescription  of  Prof.  Frank  Fry,  of  this  city,  invaluable : 

R   Ext.  cocse  fl.,  f^iii ; 

Tinct.  nucis  vom.,  f^iii ; 

Elix.  simpliois,  q.  s.  ad  f§iv. — M. 
S. — fgii  ter  die  before  meals. 

Inasmuch  as  a  proper  performance  of  the  functions  of  the 
stomach,  and  the  healthy  assimilation  of  food  dependent  there- 
upon, are  essential  in  maintaining  a  proper  nerve-tone,  it  becomes 
a  matter  of  primary  importance,  in  the  treatment  of  all  cases  of 
functional  nervous  disease,  to  obviate  dyspeptic  tendencies ;  other- 
wise a  vicious  circle  of  morbid  factors  will  become  established  : 
the  digestion  being  impaired  will  result  in  faulty  nerve-nutrition, 
and  as  a  direct  result  thereof  defective  innervation  of  the  digestive 
organs  will  inevitably  ensue.  To  prevent  such  evil  consequences 
I  have  by  a  long  experience  found  the  following  combination, 
coupled  with  a  well-regulated  diet,  most  effective.  The  charcoal 
may  be  added  or  omitted,  in  accordance  with  the  presence  or  the 
absence  of  flatulency. 

R  Lactopeptine, 

Boudault's  pepsine, 

"Willow  charcoal, 

Bismuthi  subnit.  (French),  aa  j^iiiss  ; 

Aquae,  fgi; 

Elix.  calisayse,  f^iss; 

Tinct.  cardamom,  comp.,  f5iss  ; 

Jensen's  pepsine,  gr.  xx. — M. 
S. — One  teaspoonful  after  meals. 

The  regulation  of  the  bowels  by  laxatives  is  an  indispensable 
feature  of  treatment.  Thirty  years  ago,  based  upon  Schroeder 
van  der  Kolk's  long  and  successful  experience  with  the  drug,  I 
introduced  the  use  of  buckthorn  bark  {Rhamnus  Frangulct)  in 
the  West ;  and  I  have  been  charmed  with  its  effects,  finding  that 


GEXEKAL    CEREBRAL   ANEMIA.  97 

in  every  respect  it  answers  the  purposes  for  which  it  has  been 
so  highly  extolled.  Van  der  Kolk  originally  claimed  for  it  the 
following  qualities.  In  the  first  place,  it  is  a  tonic,  and  although 
it  does  not  belong  to  the  family  of  gentians  it  acts  in  a  veri- 
similar manner.  In  the  second  place,  it  is  also  stomachic  and 
carminative.  In  the  third  place,  it  is  the  only  known  laxative 
whose  long-continued  use  permits  of  the  reduction  instead  of 
the  increase  of  the  dose.  In  the  fourth  place,  it  simply  increases 
the  alvine  actions,  without  any  debilitating  effect.  To  use  his 
own  words,  "  it  has  the  peculiarity  of  securing  a  solid  evacuation 
without  inducing  griping  or  pain,  and  at  the  same  time  it  has  no 
nauseous  taste.  It  does  not  give  rise  to  colic.  The  medicine  is 
peculiarly  suited  for  a  long-continued  employment." 

Van  der  Kolk  prescribed  it  in  decoction.  I  have  preferred  the 
fluid  extract,  made  as  follows :  bark  of  Ehamnus  Frangula,  two 
pounds ;  water,  eight  pints  ;  boil  until  reduced  to  fifty-six  fluid- 
ounces  ;  express  and  strain  ;  add  alcohol  eight  fluidounces.  Adult 
dose,  two  teaspoonfuls  at  bedtime,  as  a  laxative. 

In  severe  cases  of  constipation,  when  this  fails,  I  use  the  follow- 
ing pill : 

R   Ext.  aloes  aquosi,  gr.  Ix ; 

Ext.  colocynth.  comp.,  gr.  xx; 

Ext.  hyoscyami, 

Eel.  bovis,  aa  Qi- 
M.  et  div.  in  pilulas  no.  xx. 
S. — One  at  bedtime  when  necessary. 

I  have  very  frequently  prescribed  with  satisfactory  effect  in 
these  cases,  at  bedtime,  a  teaspoonful  of  pulvis  glycyrrhizse  comp. 
(Prussian  Pharmacopoeia) .  In  cases  where  headache  exists,  whether 
of  neuralgic,  neurasthenic,  or  migrainous  origin,  I  have  rarely 
known  the  first  dose  of  the  following  mixture  to  fail  to  produce 
immediate  relief  of  the  cephalalgia  : 

R   Antipyrin.,  ^iv; 

Caffein.  citrat. ,  gr.  viii ; 
Tinct.  strophanthi,  n\,  xv  ; 
Elix.  potass,  bromidi,  £3!  ; 
Amnion,  muriat.,  Qii ; 
Elix.  guarante,  q.  s.  ad  f^\\. — il. 
S. — Two  teaspoonfuls  every  three  hours  until  relieved  or  until  three  doses 
have  been  taken. 

7 


98  DISEASES   OF   THE   NEEVOUS  SYSTEM. 

The  cold  sponge-bath,  massage,  the  continuous  galvanic  current, 
general  faradization,  and  central  galvanization  are  invaluable  aux- 
iliary measures  of  treatment  when  judiciously  and  scientifically 
administered. 

Nitro-glycerin  has  been  highly  extolled  in  the  treatment  of 
anaemia.  I  fully  agree  with  Bartholow  when  he  remarks  that 
"  it  should  be  understood,  also,  that  the  improvement  of  nutrition 
by  increased  alimentation  is  the  more  complete  because,  by  the 
action  of  nitro-glycerin,  a  much  larger  quantity  of  blood  is  ob- 
tained by  the  tissues,  and  hence  more  of  the  nutritious  matters, 
than  would  otherwise  be  available.  The  author  has  availed  him- 
self of  these  facts,  and  has  utilized  nitro-glycerin  in  the  treatment 
of  ancemia  in  its  ordinary  form,  and  in  the  pernicious  variety. 
One  of  the  most  common  of  the  therapeutical  fallacies  of  the  day 
is  the  giving  of  iron  to  cure  anaemia,  for  in  a  large  proportion  of 
the  cases  the  iron  cannot  be  assimilated.  The  organs  concerned 
in  blood-making  may  be  in  a  pathological  condition  or  function- 
ally torpid.  Stomachal  and  intestinal  digestion  may  be  in  such  a 
state  that  the  ordinary  preparation  of  food-stuffe  is  too  imper- 
fectly performed  for  the  materials  to  be  utilized  in  blood-making. 
To  cure  anaemia  something  more  is  requisite  than  to  give  iron. 
The  functional  or  pathological  states  that  interfere  must  be  re- 
moved. "When  all  the  digestive  and  assimilative  functions  are 
restored,  failure  is  still  encountered  by  imperfect  distribution  of 
blood.  The  heart  may  be  feeble  and  act  imperfectly,  the  periph- 
eral arterioles  may  contract  on  their  lumen,  and  thus  hinder 
the  passage  of  the  blood.  Such  is  the  condition  in  a  large  pro- 
portion of  the  cases  of  anaemia.  To  bring  about  a  proper  activity 
of  the  nutrition,  it  is  necessary  to  restore  the  organs  of  circula- 
tion, and  admit  the  fullest  nutrient  supply  to  all  the  tissues.  It 
is  this  function  of  trinitrin  that  places  it  in  the  front  rank  of 
remedies  for  anaemia." 


LECTURE    y. 

MENEsGITLS. 

Acute  Idiopathic  Meningitis,  or  Leptomeningitis — Pachymeningitis — Tubercular  Men- 
ingitis— L'erebro-Spinal  Meningitis — Simple  Idiopathic  Meningitis — Chronic  Menin- 
gitis— Characters — Symptoms  :  Chill,  Fever,  Headache,  Delirium,  Vomiting,  Constipa- 
tion— First  Stage — Second  Stage — Pericarditis — Pneumonia — Rheumatism — Typhus 
and  Typhoid  Fevers — Syphilis — Hydrocephaloid — Prognosis — Causes — Convulsions 
in  Children — Treatment :  Drastic  Purgatives,  Cold  Applications,  Ergot,  Bromide  and 
Iodide  of  Potassium,  Vesicants,  Venesection,  Leeches,  Cupping,  Counter-irritants. 

Gentlemen, — We  will  now  consider  a  class  of  affections  of 
which  delirium,  is  always  a  prominent  symptom,  adopting  Da 
Costa's  method  of  grouping  the  nervous  diseases  according  to 
some  particular  common  symptom.  Among  the  numerous  acute 
affections  of  the  brain  which  delirium  always  helps  to  charac- 
terize (being  almost  one  of  their  pathognomonic  sjTnptoms !,  we 
have — 

1st.  Acute  Idiopathic  Meningitis,  or  Leptomeningitis.  2d. 
Tubercular  Meningitis.  3.  Cerebro-Spinal  Meningitis.  4th. 
Chronic  Meningitis. 

In  a  consideration  of  these  diseases  it  is  not  necessary  to  fully 
develop  all  their  details,  as  we  have  reviewed  many  of  them  with 
due  care  when  speaking  to  you  of  hypereemia  and  ansemia. 

We  therefore  have  only  to  apply  the  laws  established,  making 
but  slight  reference  to  facts  already  fully  explained. 

The  disease  which  I  will  place  before  you  to-night  is  that 
form  of  meningitis  called 

LEPTOMENINGITIS. 

The  term  leptomeningitis  signifies  an  inflammation  of  the  soft 
membranes  enveloping  the  brain  (the  pia  and  the  arachnoid). 
These  membranes  are  called  meninges ;  and  by  affixing  itis,  which 
denotes  inflammation,  the  word  meningitis  is  formed  (as  in  bron- 
chitis, pleuritis,  etc.). 

Meningitis  presents  a  few  peculiarities,  as  the  following : 

^99 


100  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  inflammation  may  be  limited  to  the  convexity  of  the  mem- 
branes, as  in  acute  idiopathic  meningitis ;  or  it  may  attack  the 
base,  as  in  tubercular  meningitis ;  or  the  dura  may  be  the  only 
membrane  implicated,  as  in  pachymeningitis,  or  the  pia  and 
the  arachnoid  may  be  the  involved  membranes. 

These  distinctions  should  be  remembered,  and,  in  order  to  im- 
press them  upon  your  memory,  I  shall  recapitulate. 

Pachymeningitis  is  an  inflammation  of  the  dura  only,  and  sel- 
dom, if  ever,  idiopathic  (that  is,  produced  without  any  apparent 
cause),  being  generally  the  result  of  an  injury  or  disease  of  the 
cranial  bones. 

Idiopathic  meningitis,  or  leptomeningitis ,  is  an  inflammation  of 
both  the  pia  and  the  arachnoid,  of  which  I  shall  soon  treat. 

Tubercular  meningitis  is  a  most  dangerous  malady,  and  usually 
attacks  children  above  two  years  of  age,  principally  those  of  a 
strumous  diathesis.  It  may  almost  be  called  an  incurable  dis- 
ease ;  for,  notwithstanding  a  few  cases  of  its  happy  termination 
are  on  record,  an  incorrect  diagnosis  in  these  cases  is  not  at  all 
improbable. 

Cerebrospinal  meningitis,  according  to  some  authors,  should  not 
strictly  be  classed  among  the  nervous  diseases,  since  it  is  claimed 
to  be  a  result  of  blood-poisoning,  and  that  it  is  only  a  form  of 
essential  fever,  the  inflammatory  products  of  which  are  in  a 
measure  directed  to  the  nervous  system. 

ACUTE   IDIOPATHIC  MENINGITIS   (LEPTOMENINGITIS). 

This  is  a  disease  which  may  occur  at  any  period  of  life,  attack- 
ing adults  as  well  as  children,  being  always  a  grave  and  dangerous 
affection.  It  is  sometimes  with  difiiculty  differentiated  from  other 
nervous  complications.  In  children  over  two  years  of  age  the 
meningitis  is  apt  to  be  of  the  tubercular  vai-iety ;  a  fact  of  great 
clinical  importance,  because  the  patient  sometimes  recovers  from 
simple,  but  almost  never  from  tubercular,  meningitis.  Hence  the 
diagnosis  of  the  latter  will  be  the  death-knell  of  your  patient, 
bringing  dismay  to  the  agonized  mother  as  she  tremblingly  awaits 
your  gloomy  verdict. 

It  is  my  desire  to  enable  you  to  fully  recognize  acute  meningitis 
without  embarrassing  your  memory  mth  lengthy  and  burdensome 


MENINGITIS.  101 

details.  AYhat  you  must  know  are  the  ordinary  and  prominent 
symptoms. 

The  initiatory  phenomenon  is  a  chill  in  the  adult,  and  a  con- 
vulsion in  the  child  (due  to  the  preternatural  mobility-  of  its 
spinal  over  its  cerebral  system),  as  is  usually  the  case  in  all  acute 
inflammatory  affections.  After  this,  reaction  will  take  place,  and 
the  febrile  exacerbation  will  be  more  or  less  intense.  The  tem- 
perature does  not  run  so  high,  however,  as  in  many  other  fevers, 
seldom  rising  above  102°  or  103°  F. ;  neither  does  it  present  any 
marked  intermissions,  but  is  continuous,  differing  in  this  regard 
from  tubercular  meningitis,  which,  hke  malaria,  is  accompanied 
by  fever  of  a  remittent  t}^e.  It  occasionally  happens  that  these 
last  two  diseases  complicate  each  other. 

After  a  cliill  and  fever,  the  next  symptom  found  in  simple 
meningitis  is  headache,  localized  in  the  frontal  region  or  generally 
diffused, — not  of  an  ordinary  character,  but  a  violent,  distress- 
ing, unmistakable  headache,  resulting  in  persistent  insomnia,  and 
torturing  the  patient  by  day  and  by  night.  His  screams  and  en- 
treaties are  beyond  expression  painful  to  hear. 

The  symptoms  do  not  necessarily  follow  the  order  of  sequence 
which  I  have  given ;  you  need  not,  therefore,  be  embarrassed  in 
your  diagnosis  on  hearing  that,  instead  of  the  chill  preceding  the 
fever,  headache,  etc.,  the  symptoms  have  all  manifested  themselves 
at  about  the  same  time. 

A  characteristic  delirium  follows  the  headache,  almost  perhaps 
without  exception,  even  in  elderly  persons,  who  have  experienced 
little  or  no  fever.  Its  peculiarity  is,  that  it  does  not  partake  of 
the  loquacious,  good-natured  character  of  deliriiun  tremens,  but 
is  so  violent  and  furious  that  the  patient  is  w4th  diflacult}"  kept 
in  bed,  and  in  his  rage  often  endeavors  to  injure  himself.  Some 
patients  have  actually  succeeded  in  destroying  themselves  when 
carelessly  watched. 

Another  characteristic  symptom  of  meningitis  is  vomiting,  whose 
peculiarities  may  sometimes  give  you  a  clue  to  the  diagnosis. 

A  great  difference  will  be  observed  between  the  vomiting  which 
accompanies  gastric,  hepatic,  or  abdominal  disorders,  and  the  vom- 
iting in  meningitis.  How,  for  instance,  does  vomiting  take  place 
in  bilious  attacks,  in  gastritis,  hepatitis,  etc.  ?  There  is  usually 
nausea,  and  the  vomiting  itself  is  painful  and  accompanied  with 


102  DISEASES   OF   THE   NERVOUS   SYSTEM. 

retching  or  straining ;  the  patient  is  greatly  distressed,  throwing 
up  all  his  food  by  violent  spasmodic  efforts.  By  pressure  of  the 
finger  upon  the  epigastrium  the  pain  will  be  increased  and  vomit- 
ing aggravated. 

This  phenomenon  in  brain-diseases  offers  very  distinctive  feat- 
ures ;  the  vomiting  occurring  without  the  slightest  effort, — almost 
spontaneously,  in  fact, — and  unaccompanied  by  pain  or  nausea, 
features  stamping  it  characteristically  as  sympathetic  with  disease 
of  the  brain.  The  vomiting  resulting  from  gastric  affections  is 
generally  relieved  by  the  application  of  a  mustard  plaster  over 
the  epigastrium.  In  cerebral  trouble,  however,  the  plaster  should 
be  placed  upon  the  nape  of  the  neck. 

I  must  not  neglect  to  mention  another  symptom,  which  is  eon- 
stipation,  the  bowels  ordinarily  being  quite  difficult  to  move. 

There  are  few  or  no  premonitory  symptoms ;  the  onset  of  the 
disease  is  characteristically  sudden  and  violent. 

The  delirium  may  be  sometimes  constant,  and  sometimes,  though 
very  rarely,  remittent  in  form ;  at  other  times  it  is  quite  maniacal 
in  character. 

Convulsions  seldom  occur  early,  except  in  very  young  children 
and  in  the  septic  and  purulent  varieties  of  the  disease. 

Muscular  rigidity  and  a  tendency  to  opisthotonos  are  rare,  being 
more  frequently  encountered  in  tubercular  meningitis. 

Paresis,  sometimes  unilateral  in  form,  is  complete  or  lasting 
only  in  rare  cases. 

When  the  meningeal  inflammation  affects  more  particularly  the 
neighborhood  of  the  motor  tract, — namely,  the  central  convolu- 
tions and  paracentral  lobule, — hemiplegia  preceded  by  unilateral 
convulsions  not  infrequently  occurs. 

Paralysis  of  the  cranial  nerves  occurs  very  rarely,  and  is  more 
characteristically  a  symptom  of  tubercular  or  chronic  basilar  men- 
ingitis. In  some  few  instances  slight  ptosis  and  strabismus  are 
observable. 

In  old  persons  delirium  and  somnolence  usher  in  the  disease. 

"Vertigo  of  the  cerebral  type,  as  described  in  the  previous 
lecture,  frequently  occurs  at  the  onset,  but  is  rarely  a  constant 
symptom. 

Pain,  constant  and  severe,  is  nearly  always  present  in  all  forms 
of  meningitis,  especially  in  the  early  stages. 


MENINGITIS.  103 

Hypersestheslse  of  the  nerves  of  special  sense,  usually  diffused, 
appear  early. 

Retraction  of  the  head,  as  stated  above,  does  not  often  compli- 
cate acute  meningitis  of  the  convexity,  as  it  does  so  frequently 
tubercular  and  cerebro-spinal  meningitis. 

Optic  neuritis  is  sometimes  found,  especially  about  the  end  of 
the  second  "week,  but  is  observed  far  oftener  in  tubercular  menin- 
gitis ;  it  is  caused  by  an  extension  of  the  inflammation  down  the 
sheath  of  the  nerves,  and  often  into  the  deep  ocular  tissues. 

The  sphincters  are  often  involved  towards  the  termination  of 
the  disease,  retention  of  urine  existing,  and  sometimes  incontinence 
of  faeces. 

The  pupils  are  contracted  in  the  early  stages  of  the  disease,  and 
dilated  towards  its  termination ;  inequality  of  the  pupils  is  not 
as  common  in  this  variety  as  in  some  other  forms  of  meningitis. 

Sloughs  and  bed-sores  may  be  developed,  and  should  be  care- 
fully guarded  against. 

Respiration  is  sometimes  quickened,  disturbed,  and  more  or 
less  impeded,  but  does  not  partake  of  the  Cheyne-Stokes  altera- 
tion of  rhythm,  a  symptom  almost  pathognomonic  of  tubercular 
meningitis. 

The  fever  in  acute  idiopathic  meningitis  is  rarely  high,  ranging 
from  101°  to  103°  F. ;  it  is  continuous  in  character,  with  varia- 
tions, but  without  the  marked  remissions  of  tubercular  meningitis. 
In  the  purulent  form  the  temperature  may  rise  to  105°  F.  In 
fatal  cases  the  temperature  prior  to  death  may  rise  to  106°  or 
108°  F. 

We  have  now  considered  the  principal  symptoms  of  importance 
characterizing  the  first  stage  of  the  disease.  You  should  remem- 
ber them,  since  they  are  not  always  described  in  this  order.  You 
will  find  these  symptoms  far  from  corresponding  accurately  with 
the  typical  descriptions.  In  fact,  you  need  not  expect  the  first, 
second,  and  third  stages  of  some  writers  to  succeed  one  another  in 
regular  tiu-n. 

It  is  only  an  arbitrary  plan  thus  to  divide  some  maladies,  which 
custom  I  have  followed  in  order  to  make  matters  clearer  to  your 
minds.  Consequently,  be  prepared  to  find  upon  your  first  visit 
perhaps  some  characteristics  of  nearly  every  stage  of  the  disease 
existing  at  the  same  time. 


104  DISEASES   OF   THE   NERVOUS  SYSTEM. 

In  affections  of  the  brain,  symptoms  of  irritation  usually  appear 
first,  and  are  succeeded  by  those  of  depression,  though  this  order 
is  not  absolute,  the  symptoms  of  depression  being  sometimes  initia- 
tory, as,  for  instance,  in  a  patient  stricken  down  by  an  attack  of 
cerebral  hemorrhage, — where  you  will  have  a  comatose  state  from 
the  commencement.  In  proportion  to  the  intensity  of  the  attack 
will  you  find  the  sequence  of  the  symptoms  tardy  or  rapid.  When 
extremely  violent,  as  in  the  memn^ife/oMcZro^/anfe,  those  of  depres- 
sion set  in  at  once  :  you  find  your  patient  comatose  on  the  first 
visit,  and  dead  on  the  second.  But  in  milder  cases  the  different 
stages  are  better  marked,  symptoms  of  irritation  often  existing  for 
several  days  before  those  of  depression  or  coma.  And  this  latter 
condition  is  always  to  be  apprehended  ;  for  it  has  usually  a  fatal 
termination.  In  these  cases,  the  delirium  passes  into  stupor ;  you 
shake  your  patient  to  no  avail ;  you  cannot  arouse  him ;  the  stupor 
deepens  into  coma, — his  last  sleep. 

The  corresponding  symptoms  keep  pace  with  these  changes ; 
and  pari  passu  the  pulse  becomes  frequent,  feeble,  irregular,  and 
jerking,  the  skin  is  dry  and  parched,  the  breathing  stertorous,  and 
the  patient's  vital  powers  rapidly  give  way.  He  dies  of  the  same 
coma  that  we  find  in  cerebral  hemorrhage,  in  epilepsy,  in  urae- 
mia, etc.,  except  that  in  epilepsy  it  is  transitory.  This  coma  is 
the  second  stage  of  meningitis,  and  is  an  adynamic  coma.  I  use 
the  word  adynamic  here  as  we  use  the  term  typhoid  to  express  the 
low  ebb  of  the  vital  powers,  with  dry  tongue  and  feeble  pulse, 
found  in  typhoid  fever,  but  which  we  apply  also  to  similar  con- 
ditions present  in  other  diseases. 

Watson  graphically  describes  the  manner  of  dying  by  apnoea, 
asthenia,  anaemia,  and  coma.  In  meningitis,  the  patient  dies  of 
coma.  If  you  bear  in  mind  all  the  points  that  have  been  already 
given,  you  will  have  little  difficulty  in  forming  a  clear  idea  of 
meningitis. 

You  will  perhaps  ask.  How,  with  this  grouping  of  symptoms, 
will  it  be  possible  for  us  to  distinguish  meningitis  from  other 
diseases  of  the  brain  ?  It  is  possible  for  any  man  to  make  mis- 
takes in  this  as  in  other  diseases ;  but  the  common  blunders  which 
you  would  be  liable  to  make  if  not  forewarned  I  will  endeavor  to 
guard  you  against. 

The  most  important  point,  in  my  estimation,  is  the  diagnosis. 


MENINGITIS.  105 

A  disease  which  you  might  take  to  be  simple  meningitis,  and 
^Yhich  has  misled  some  good  diagnosticians,  is — 

Pericarditis. — In  this  disease  there  are  sometimes  indications 
similar  to  those  of  the  foregoing  affections, — viz.,  the  head-symp- 
toms. Should  you  make  a  hurried  examination,  you  may  conclude 
that  the  case  is  one  of  meningitis,  and  you  will  resort  to  active 
treatment, — purging,  bleeding,  etc., — a  treatment  not  quite  in 
accordance  with  the  modern  mode  of  management  of  pericardial 
inflammation.  I  advise  you  to  guard  against  this  fallacy,  and  in 
such  cases  always  to  examine  the  thorax. 

I  once  had  a  patient  in  whom  several  nervous  symptoms  pre- 
sented themselves, — headache,  vomiting,  etc., — and  I  was  almost 
inclined  to  believe  it  to  be  a  case  of  meningitis ;  for  although  the 
patient  had  pains  in  the  prsecordial  region  he  referred  the  severest 
pain  to  the  head.  Certain  peculiar  disturbances  of  the  pulse  and 
of  the  respiration,  however,  soon  put  me  on  the  proper  track  to 
diagnosticate  pericarditis. 

Pneumonia  is  another  malady  which  sometimes  presents  head- 
symptoms  similar  to  those  of  meningitis,  the  auscultatory  evidence 
in  the  first  stages  of  the  former  disease  being  frequently  unsatis- 
factory. I  have  seen  a  patient  who  presented  several  suspicious 
symptoms  of  pneumonia,  but  I  was  unable  to  detect  a  crepitant 
rale,  and  there  was  no  dulness  on  percussion.  I  finally  examined 
the  axillary  space,  when  a  distinct  crepitation  was  manifest. 

When  you  are  at  a  loss  to  decide  whether  the  disease  is  a  menin- 
gitis, a  pericarditis,  or  a  pneumonia,  always  recollect  that  delirium 
usually  accompanies  a  consolidation  in  the  a^je.r  of  the  lungs,  and 
that  auscultation  will  furnish  the  desired  information.  Experience 
has  taught  me  that  the  less  medication  employed  in  pneumonia  the 
better,  since  it  is  a  strictly  cyclical  ailment,  whilst  in  meningitis 
active  treatment,  on  the  contrary,  may  be  of  some  benefit. 

Another  source  of  error  arises  in  some  cases  of  rheumatism, 
where  the  blood-poison  is  expending  its  virulence  upon  the  brain, 
or  perhaps  where  symptoms  formerly  attributed  to  metastasis 
supervene.  I  remember  having  suddenly  lost  a  patient  once  with 
rheumatism  accompanied  with  suddenly-developed  brain-symp- 
toms like  those  of  meniug-itis. 

Examinations  of  the  brain,  in  parallel  cases  of  rheumatism,  have 
been  made  by  Trousseau,  without  discovering  any  confirmatory 


106  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

evidence  of  cerebral  inflammation,  where  death  was  preceded  by 
well-marked  meningeal  symptoms.  The  efforts  of  other  investi- 
gators, however,  have  been  attended  with  contrary  results.  In 
rheumatism  with  an  existing  tendency  towards  the  development 
of  such  complications,  it  is  best  to  be  ever  upon  your  guard ;  never 
be  over-confident  in  your  prognosis.  Da  Costa  reports  cases, 
moreover,  of  undoubted  meningeal  rheumatism. 

Another  set  of  head-symptoms  intimately  connected  with  the 
progress  of  typhus  and  typhoid  fevers  may  also  be  mistaken  for 
those  of  meningitis. 

Typhus  or  "  ship"  fever  is  a  disease  only  exceptionally  seen  as 
far  west  as  St.  Louis.  In  typhoid  fever,  especially  in  very  ner- 
vous persons,  the  head-symptoms  are  quite  prominent,  and  there  is 
much  nervous  irritation.  The  Germans  call  this  disease  "  Nerven- 
fieber."  To  treat  this  fever  actively  would  be  a  most  unfortunate 
and  unpardonable  blunder ;  therefore,  examine  the  patient's  abdo- 
men, to  ascertain  whether  or  not  it  is  tympanitic  and  painful,  if 
pressure  gives  rise  to  gurgling  and  localized  tenderness  in  the 
right  iliac  fossa,  and  the  presence  or  absence  of  the  characteristic 
lenticular  eruption  of  typhoid  fever. 

Syphilis  also  is  said  sometimes  to  produce  marked  symptoms  of 
cerebral  and  meningeal  irritation ;  *  and  still  another  disease  is 
hydrocephaloid.  Of  this  I  had  intended  to  speak  more  at  length 
in  this  connection,  but  shall  defer  it  until  reviewing  the  tubercular 
form  of  meningitis. 

The  prognosis  in  idiopathic  meningitis  is  very  unfavorable  ;  so 
be  cautious  in  giving  your  opinion,  for  the  contingencies  are  such 
as  to  invest  the  result  with  great  uncertainty. 

The  causes  are  excessive  mental  fatigue,  over-exposure  to  the 
rays  of  the  sun,  severe  blows  on  the  cranium,  rheumatism,  and, 
perhaps,  syphilis.  Septicsemia  often  causes  meningitis,  which  is 
then  of  the  purulent  variety. 

De  Cazal  records  a  case  of  meningitis  consecutive  to  facial  ery- 
sipelas. The  infection  extended  from  a  phlegmonous  abscess  at 
the  inner  angle  of  the  eye,  along  the  sheath  of  the  optic  nerve,  to 
the  base  of  the  brain.  B.  Langrau  reports  three  cases  of  menin- 
gitis developing  under  circuriistances  which  led  him  to  believe  that 

*  See  lecture  on  syphilitic  nervous  affections,  vol.  ii. 


MEXIXGITIS.  107 

educational  pressure  and  resulting  brain-overrvork  constituted  the 
exciting  cause.* 

The  exanthemata,  typhoid  fever,  pneumonia,  and  endocarditis 
are  sometimes  followed  bv  meningitis. 

ANATOMICAL.  APPEAEAITCES. 

As  regards  the  morbid  appearances  of  this  disease,  recollect  that 
the  dura  mater  is  not  involved,  and  that  the  condition  of  the  pia 
and  of  the  arachnoid  depends  upon  the  intensity  of  the  attack. 
There  is  an  exudation  of  pus,  and  more  or  less  thickening  of  the 
membranes,  which  present  a  pearly  and  opaque  appearance.  The 
purulence  occurs  sometimes  verj  early.  I  have  read  of  cases  in 
children  where  it  was  discerned  witliin  twenty-four  hours  from  the 
commencement  of  the  disease. 

The  anatomical  changes  may  involve  all  portions  of  the  pia 
and  arachnoid,  but  they  are  usually  more  prominent  at  the  con- 
vexity than  at  the  base.  There  is  intense  congestion  of  the  pia. 
Great  opacity  of  both  the  pia  and  arachnoid  are  manifest,  with 
collections  of  ^vhite,  yellow,  and  almost  purulent  lymph,  and  large 
quantities  of  serum  effused  imder  the  arachnoid. 

The  inflammation  sometimes  extends  to  the  substance  of  the 
brain  and  to  the  inner  surface  of  the  dura,  which  may  be  thickened 
and  congested.  In  some  instances  one  or  two — in  exceptional 
cases  all  three — membranes  may  be  adherent.  Sometimes  the  pia 
cannot  be  separated  from  the  cortex  without  lacerating  it. 

The  cortex  cerebri  may  be  likewise  inflamed.  The  cerebro- 
spinal fluid  is  often  increased  in  quantity,  and  cloudy  or  opaque. 
The  ependyma  of  the  ventricles  may  be  inflamed,  and  the  periph- 
eral portion  of  the  brain  may  be  softened  or  present  signs  of  marked 
inflammatory  changes.     The  lateral  ventricles  are  often  distended. 

There  may  be  a  gelatiniform  exudation  and  the  formation  of 
false  membranes. 

The  meningeal  membranes  in  purulent  meninigitis  are  covered 
with  greenish-yellow  and  sometimes  offensive  pus,  more  particu- 
larly observable  at  the  convexity. 

Charcot  justly  claims  that  it  is  rare  to  encounter  purulent  collec- 
tions in  the  arachnoidean  cavity ;   more  frequently  pus  is  found 

*  Gray,  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 


108  DISEASES   OF   THE   NERVOUS   SYSTEM. 

under  the  arachnoid  membrane ;  sometimes,  however,  the  pus 
collects  between  the  inner  table  of  the  skull  and  the  dura ;  finally, 
under  the  influence  produced  by  cranial  hyperostosis,  pus  accumu- 
lates between  the  two  layers  of  the  dura. 

It  is  an  important  clinical  fact  that  in  very  young  children  the 
disease  is  not  ushered  in  by  a  chill,  but  by  convulsions, — a  result 
partially  due  to  their  liability  to  convulsions  in  consequence,  as 
West  says,  of  the  preternatural  mobility  of  their  nervous  system, 
which  is  therefore  easily  irritated  by  trifling  disturbances,  whether 
originating  from  teething,  worms,  fevers,  or  the  exanthemata. 

As  to  treatment,  I  have  not  much  to  say.  I  do  not  believe  in 
the  efficacy  of  tartar  emetic,  calomel,  or  repeated  and  copious  ven- 
esections in  the  treatment  of  inflammation,  having  known  iritis 
to  occur  during  mercurial  ptyalism.  You  can  accomplish  some- 
thing by  administering  drastic  purgatives,  and  I  have  great  faith 
in  the  good  effects  produced  by  cathartics,  as  derivatives,  in  cer- 
tain affections  of  the  brain.  As  a  matter  of  course,  they  must  be 
used  with  caution,  or  the  result  will  be  unfavorable ;  but  there  is 
a  medium  in  all  things,  even  in  the  administration  of  beef  tea  or 
water.  At  the  very  beginning  of  the  disease,  a  purgative  is  highly 
beneficial, — the  old  "  ten  and  ten"  (calomel,  ten  grains,  jalap,  ten 
grains)  being  probably  as  good  as  anything  else  you  can  use; 
sometimes  croton  oil  or  elaterium. 

Cold  applications  to  the  head,  by  means  of  ice-bags,  must  not 
be  neglected ;  hut  never  fail  to  give  precautionary  directions  about 
applying  the  ice  at  intervals,  and  moving  it  about ;  for  I  have  seen 
cases  where  the  scalp  had  been  actually  frozen.  Ergot  is  of  ad- 
vantage in  meningitis,  by  its  action  upon  the  vaso-motor  nerves, 
causing  contraction  of  the  blood-vessels ;  and  its  action  may  be 
intensified  by  the  addition  of  bromide  of  potassium.  Iodide  of 
potassium  also  bears  a  good  reputation,  being  with  many  writers 
the  remedy  par  excellence ;  it  is  to  be  given  freely  and  boldly, 
especially  where  a  rheumatic  or  a  syphilitic  taint  exists. 

Should  the  disease  become  subacute,  shave  the  scalp,  and  pustu- 
late it  with  croton  oil :  this  measure,  in  children  especially,  fre- 
quently has  an  admirable  effect.  In  cases  with  sthenic  symptoms, 
you  might  resort  to  venesection,  or  to  the  application  of  leeches  to 
the  mastoid  processes,  the  anus,  the  Schneiderian  membrane,  or  the 
occipital  protuberance.     Cupping,  also,  is  very  useful.     After  the 


MENINGITIS.  109 

cups  use  counter-irritants ;  apply  mustard  plasters  to  the  feet, 
wrap  them  in  warm  fomentations  and  cover  them  with  blankets. 
Remember  Boerhaave's  celebrated  maxim  :  "  Keep  the  head  cool, 
the  feet  warm,  the  bowels  regular."  In  this,  as  in  other  inflam- 
matory fevers,  give  judicious  nourishment,  like  beef  tea,  milk, 
or  other  food  easy  of  digestion  and  absorption :  for  in  most  of 
these  troubles  i;here  is  a  moment  of  crisis  which  is  liable  to 
carry  off  the  patient  unless  the  vital  powers  have  been  sufficiently 
supported.  If,  in  spite  of  all  this,  your  patient  should  show  signs 
of  approaching  death,  you  might  tlien  even  venture  to  administer 
stimulants. 


LECTURE   YI. 

TUBERCUXrAE   MENINGITIS. 

Acute  Idiopathic  Meningitis — Anatomical  Lesions  a  Peculiarity — Acute  Hydrocephalus 
— Symptoms :  Period  of  Invasion,  Gradual  Impairment  of  Health,  Change  of  Habits 
and  Temper,  Headache — Importance  of  Cephalalgia — Stages :  Slow  Pulse,  Suspirious 
Eespiration,  Cerebral  Maculse,  Boat-shaped  Abdomen,  Flush  and  Pallor,  Cephalic 
Cry,  Remission  in  Fever,  Increased  Somnolence,  Coma,  Changes  in  Paralytic  Phe- 
nomena—  Sources  of  Error:  Bilious  Intermittent  Fever,  Typhoid  Fever,  Hydro- 
cephaloid  of  Marshall  Hall,  Partial  Anaemia — Optic  Neuritis — Prognosis — Treatment 
— Koch's  Injections  in  Tubercular  Meningitis. 

Gentlemen, — In  my  last  lecture,  when  speaking  of  acute 
idiopathic  meningitis,  I  remarked  that  one  of  its  most  salient  and 
characteristic  features  is  its  occurrence  in  children  generally  under 
the  age  of  two  years  or  above  the  age  of  ten,  or  in  adults.  I 
also  stated  that  in  children  acute  menmgitis  commences  with  con- 
vulsions, and  that  their  early  appearance  or  recurrence  is  quite 
characteristic  of  this  disease.  Simple  meningitis  we  found  to  be  an 
inflammatory  affection,  accompanied  by  fever,  and  hence  readily 
discriminated  from  active  hypersemia  of  the  brain,  by  placing  the 
thermometer  in  the  axilla.  Convulsions  preceding  acute  disease  in 
children  are  simply  premonitory  symptomatic  indications  of  greater 
or  less  trouble,  but  are  significant  of  no  particular  pathological 
state.  They  are  produced  by  the  presence  of  worms,  dentition, 
the  exanthemata,  epilepsy,  brain-alfections,  or  toxaemia  ;  in  short, 
they  occur  in  all  cases  of  acute  affections  or  where  some  reflex 
irritation  has  produced  central  or  functional  nervous  disturbances. 
If  you  have  carefully  retained  what  I  told  you  when  describing 
simple  meningitis,  you  will  recollect  that  I  also  referred  digres- 
sively  to  tubercular  meningitis,  stating  that  it  usually  attacks 
children  between  the  ages  of  two  and  ten  years.  It  is  a  disease 
peculiar  to  childhood,  and  is  generally  treated  of  in  works  upon 
the  diseases  of  children,  but  it  may  occasionally  attack  adults  of 
110 


TCBEECULAR    MEXINGITIS.  Ill 

a  scrofulous  diathesis,  or  in  whom  tuberculous  deposits  exist  in 
the  lungs,  mesentery,  or  other  organs. 

The  anatomical  lesions  of  this  malady  differ  from  those  of  sim- 
ple meningitis.  The  membranes  involved  in  both  diseases  are  the 
same,  it  is  true,  but  the  latter  affects  the  convexity,  while  tuber- 
cular meningitis  attacks  the  6a.se,  of  the  brain,  whence  the  French 
derive  their  name  of  "  meningite  de  la  base."  Xou  occasionally 
find  described  a  disease  called  acute  hydrocephalus.  In  what  re- 
spects does  it  essentially  differ  from  simple  acute  idiopatliic,  or 
from  tubercular,  meningitis  ?  It  is  only  another  name  for  tuber- 
cular meningitis.  It  is  called  acute  hydrocephalus  because  the 
disease  was  so  termed  by  Dr.  Whytt,  of  Edinburgh,  who  origi- 
nally described  it  as  "acute  dropsy  of  the  brain,"  "ventricular 
meningitis.''^  This  name  does  not,  however,  express  the  original 
character  of  the  malady  itself,  but  only  one  of  its  results.  More- 
over, in  all  forms  of  tubercular  meningitis  there  is  usually  an 
exudation  of  fluid  into  the  ventricles,  causing  softening  by  press- 
ure, and  a  kind  of  saponified,  friable,  cedematous  condition  of 
the  surrounding  brain-structure,  while  in  simple  meningitis  these 
cavities  are,  as  a  rule,  empty.  The  name  acute  hydrocephalus, 
therefore,  expresses  only  a  result ;  and  you  might  with  as  much 
propriety  call  typhoid  fever  a  disease  of  Peyer's  glands,  though 
the  ulceration  of  these  follicles  is  but  a  consequence  of  the  action 
of  its  peculiar  materies  morbi.  Now,  one  of  the  principal  lesions 
in  tubercular  meningitis  is  this  dropsical  effusion  in  the  ventricles 
of  the  brain;  but  we  have  others  just  as  important,  as,  for  in- 
stance, the  tuberculous  deposit  at  the  base  of  the  brain,  or  in  the 
meshes  of  the  pia  mater,  or  in  the  fissure  of  Sylvius.  Acute 
hydrocephalus  is,  therefore,  an  improper  appellation. 

Perhaps  it  would  not  be  unsuitable  in  this  place  for  me  to  say 
that,  in  my  opinion,  it  is  unadvisable  to  designate  a  disease  by  the 
name  of  an  individual.  "Duchenne's  disease"  implies  nothing 
in  relation  to  its  pathology  or  symptomatology ;  but  "  progressive 
locomotor  ataxia,"  or  "  sclerosis  of  the  posterior  columns  of  the 
spinal  cord"  (Hammond),  immediately  conveys  to  the  mind  the 
principal  characteristic  features  of  the  disorder.  The  same  may 
be  said  in  regard  to  "  Bright's  disease"  for  certain  affections  of 
the  kidneys,  and  "  Addison's  disease"  for  certain  lesions  of  the 
suprarenal    capsules.      Acute   hydrocephalus   is   the   older,   and 


112  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tubercular  meningitis  the  more  recent,  designation  for  the  same 
disorder. 

What  are  the  principal  symptoms  of  tubercular  meningitis? 
I  say  principal,  because  I  will  not  consider  its  minutiae.  With 
Trousseau,  I  believe  that  too  great  importance  cannot  be  attached 
to  the  period  of  invasion  as  a  diagnostic  point.  A  due  recognition 
of  this  is  an  important  preliminary  step  in  untying  the  Gordian 
knot  of  diagnosis.  In  acute  idiopathic  meningitis  there  is  a 
stormy  outset,  the  fever  and  brain-symptoms  rendering  the  period 
of  invasion  strikingly  alarming.  But  in  tubercular  meningitis 
the  period  of  invasion  is  so  very  peculiar  and  insidious  that  it  can- 
not ordinarily  be  mistaken  by  any  careful  observer.  The  child, 
being  of  strumous  diathesis,  of  scrofulous  parentage  or  ancestry, 
ceases  to  be  healthy.  It  is  not  at  once  seized  with  tubercular 
meningitis  while  enjoying  perfect  health,  as  in  acute  meningitis, 
but  there  is  a  gradual  failing  of  the  general  health,  and  emaciation 
commences.  This  change,  the  beginning  of  which  was  scarcely 
noticed,  at  last  becomes  not  only  evident  but  striking.  It  is 
sometimes  rapid,  and  the  child,  who  perhaps  was  formerly  fat  and 
vigorous,  the  very  picture  of  health,  soon  loses  flesh,  and  becomes 
greatly  emaciated.  While  this  is  in  progress,  another  condition 
attracts  our  notice, — one  on  which  Trousseau  lays  great  stress. 
This  is  the  moral  change,  manifested  in  the  habits  and  temper  of 
the  child.  The  little  patient,  who  had  been  formerly  perhaps  of 
playful  disposition,  grows  irritable  and  peevish ;  objects  which 
formerly  were  incitements  to  playfulness  now  cease  to  attract  at- 
tention. The  child  becomes  irritable,  taciturn,  morose,  and  dis- 
agreeable, indifferent  to  pettings  and  caressings,  which  formerly 
were  eagerly  sought  for  and  fully  appreciated,  and  experiences  no 
interest  or  pleasure  in  the  company  of  its  little  playfellows  or  in 
its  accustomed  frolics.  At  length  the  mother  becomes  seriously 
alarmed,  and  is  positive  in  asserting  that  there  is  something  the 
matter  with  the  child,  who  very  likely  at  this  period  begins  to 
evince  the  existence  of  violent  headache.  This  cephalalgia  will 
come  on  paroxysmally,  and  the  child,  whilst  running  about,  will 
suddenly  stop,  lean  against  something,  jDut  its  hand  to  its  head, 
and  complain  of  violent  pain.  It  will  also  be  seized  with  vomit- 
ing,— not  the  ordinary  vomiting  from  gastric  disturbances,  but 
true  cerebral  vomiting,  which  I  described  in  my  last  lecture. 


TUBERCULAR   MENINGITIS.  113 

Of  course  the  parents  are  now  extremely  solicitous,  and  a  phy- 
sician is  sent  for.  Well  may  they  be  frightened ;  for  although 
headache  is  not  infrequent  in  children^  still,  when  it  follows  slow 
emaciation  and  the  other  symptoms  described,  the  mother  feels  that 
there  is  probably  some  grave  affection  undermining  the  health  of 
the  little  one,  and  her  suspicions  are  well  founded.  If  the  physi- 
cian summoned  be  the  regular  family  attendant,  he  has  undoubt- 
edly already  observed  the  nature  and  suspected  the  cause  of  the 
ominous  changes  in  the  child,  aud  his  case  is  pretty  well  made 
out  before  he  arrives  at  the  house.  But  if  he  be  a  stranger  un- 
acquainted with  the  family,  he  will  learn,  upon  inquiring  into  the 
history  of  the  case,  that  the  child  is  suffering  from  severe  head- 
ache, perhaps  vomiting,  and,  moreover,  has  been  ailing  for  an  in- 
definite period,  with  well-marked  change  of  character  and  moral 
perversion,  its  health  meanwhile  gradually  declining.  Do  not 
lose  sight  of  these  facts ;  they  are  exceedingly  important ;  you 
must  recollect  them,  as  they  will  prove  serviceable.  In  order  to 
show  the  importance  of  cephalalgia  in  children  as  a  symptom,  I 
will  relate  a  case  which  occurred  in  my  own  experience. 

I  was  once  called  upon  to  visit  a  young  child  suffering  from 
severe  headache.  The  attending  physician  was  absent,  and  my 
immediate  presence  was  desired.  On  my  way  to  the  house,  it 
occurred  to  me  that  there  might  be  something  grave  about  this 
case,  requiring,  as  it  did,  the  immediate  attendance  of  a  medical 
man  to  relieve  the  suffering,  not  even  awaiting  the  return  of  the 
regular  doctor.  On  examination,  I  found  that  the  headache  had 
lasted  several  days,  that  contraction  of  the  pupils  existed,  with 
photophobia,  intolerance  of  sound,  and  marked  fever,  the  temper- 
ature being  103°  F.  I  immediately  jumped  at  a  diagnosis,  which 
I  jcaution  you  never  to  do ;  for  the  disease  might  have  been  re- 
mittent fever,  which  in  children  often  produces  violent  head- 
symptoms,  which  are  cured  by  quinine.  But  I  felt  justified  in 
the  conclusion  I  had  so  rapidly  arrived  at,  because,  upon  inquiring 
concerning  the  previous  health  of  the  patient,  I  learned  that  it 
had  failed  gradually,  that  the  attack  had  been  insidious,  and,  as 
the  mother  expressed  it,  "  she  didn't  exactly  know  when  the  child 
first  got  sick."  After  hearing  this,  reviewing  the  other  symp- 
toms, and  revolving  them  in  my  mind,  I  was  convinced ;  and,  to 
ray  sorrow,  I  diagnosticated  tubercular  meningitis,  without  com- 

8 


114  DISEASES   OF   THE   NERVOUS   SYSTEM. 

mimicating  my  fears  to  the  family.  The  same  afternoon  I  met 
the  attending  physician,  informed  him  of  my  visit  to  the  child, 
and  commmiicated  to  him  my  fears  and  diagnosis.  He  asserted 
that  I  was  mistaken, — that  the  child  was  only  suffering  from  a 
"  neuralgic"  affection.  I  reminded  him  that  Dr.  West  states  that 
neuralgia  is  of  exceedingly  rare  occurrence  in  children ;  nor  would 
it  be  accompanied  by  fever,  or  preceded  by  slow  and  gradual  de- 
terioration of  health.  We  parted,  and  a  few  days  afterwards  I 
was  informed  that  my  diagnosis  had  been  correct,  and  that  death 
had  rapidly  supervened.  When  you  consider  that  Trousseau,  with 
all  his  opportunities,  immense  practice,  and  enormous  consultation 
experience,  emphatically  states  that  he  met  with  only  two  cases  of 
tubercular  meningitis  that  recovered,  and  that  even  then  it  was 
highly  probable  that  he  had  been  mistaken  in  his  diagnosis,  you 
will  readily  be  convinced  of  the  hopelessness  of  the  affection. 
Therefore,  beware  of  neuralgia  ui  children ;  for,  generally,  there 
is  something  more  serious  underlying  the  superficial  symptoms. 

Let  us  now  consider  the  stages  of  this  illness.  I  have  already 
stated  that  I  do  not  in  general  approve  of  an  arbitrary  division 
of  disease  into  stages ;  as  they  so  seldom  correspond  to  the  real 
accession  and  development  of  the  morbid  phenomena,  which  vary 
in  different  cases,  untrammelled  by  artificial  limitations.  It  is  a 
source  of  fallacy,  therefore  ;  but,  as  it  is  the  custom  to  divide  dis- 
ease into  stages,  I  shall  give  you  the  different  symptoms  which, 
as  nearly  as  possible,  constitute  those  of  tubercular  meningitis. 
We  have  first  the  period  of  invasion,  already  described,  with  irri- 
tability, fretfulness,  moral  changes,  etc. ;  then  fever,  accompanied 
by  a  slightly  accelerated  pulse,  delirium,  headache,  cerebral  vomit- 
ing, restlessness,  wakefulness,  constijjation,  and  contraction  of  the 
pupils.  These  characterize  what  is  termed  the  first  stage  of  the 
disease. 

We  have  here  the  symptoms  of  excitation,  of  hypersemia,  with 
the  addition  of  fever.  When  this  stage  has  passed  (always  sup- 
posing that  we  have  this  regular  succession  of  phenomena),  the 
pulse  becomes  remarkably  slow, — the  so-called  "  cerebral  pulse," — 
falling  to  seventy,  sixty,  or  even  fifty  per  minute  in  very  young 
children,  and  there  exists  likewise  an  interference  with  its  rliythm. 
A  peculiar  emban^assment  of  respiration,  not  enough  to  amount 
to  a  dyspnoea  or  an  orthopnoea,  is  produced ;  but  there  is  a  rhyth- 


TUBERCULAR   MENUsGITIS.  115 

mical  disturbance  which  sometimes,  though  not  always,  corre- 
sponds to  the  change  in  the  pulse.  About  this  time  a  kind  of 
mottling  appears  upon  the  skin,  which  has  been  described  as  cere- 
bral maculce,  and  upon  drawing  your  finger  over  it,  quite  dis- 
tinct traces  are  left,  which  fade  gradually.  This  is  not,  however, 
essentially  characteristic  of  the  disease. 

You  will  observe  a  peculiar  appearance  of  the  abdomen,  consti- 
tuting a  sort  of  boat-shaped  excavation ;  the  intestines  sink,  the 
abdominal  parietes  shrink,  and  the  superior  spinous  processes 
of  the  ilia  come  out  in  bold  relief.  This  symptom,  though  not 
pathognomonic,  is  still  quite  characteristic  of  the  affection,  and 
should  always  be  sought. 

There  are  remarkable  alternations  of  flushing  and  pallor  of  the 
countenance  present  in  all  the  varieties  of  meningitis,  due  perhaps 
to  a  peculiar  state  of  the  vaso-motor  nerves,  causing  the  alternate 
contraction  and  relaxation  of  the  blood-vessels  which  they  control ; 
and  when  you  examine  the  child,  you  will  sometimes  observe  its 
face  glowing  and  congested,  and  there  may  be  a  sudden  accession 
of  marked  wanness.  From  these  symptoms  you  will  justly  con- 
clude that  you  are  dealing  with  a  case  of  meningitis,  and  that  the 
danger  is  imminent  and  threatening. 

There  is  also  developed  a  cephalic  cry,  the  result  of  pain, — a 
peculiar,  piercing,  wild,  automatic  shriek,  never  to  be  forgotten 
when  once  heard.  After  you  have  seen  a  few  cases  of  tubercular 
meningitis,  these  different  symptoms  will  become  indelibly  im- 
pressed upon  your  memory.  The  headache,  fever,  flushing,  pallor, 
sunken  abdomen,  stupor,  disturbances  of  pulse  and  respiration,  are 
quite  characteristic,  but,  in  reality,  are  merely  the  prodromes  of 
the  third  stage, — coyna. 

In  the  second  stage  there  are  very  often  remissions  of  the  fever, 
sometimes  so  marked  that  they  may  lead  you  to  think  you  have 
made  a  mistake  in  diagnosis,  and  you  will  administer  quinine, 
hoping  to  check  the  fever,  as  probably  of  malarial  origin.  But 
remember  that  this  is  merely  clutching  at  a  straw,  as  these  re- 
missions are  peculiarly  characteristic  of  the  disease,  and  may  be 
observed  even  in  its  last  stage,  after  coma  has  set  in. 

During  the  second  stage  a  marked  symptom  is  increased  somno- 
lence. In  the  first  stage,  owing  to  its  great  irritability,  the  child 
is  annoyed  by  the  doctor's  presence,  lights,  sounds,  etc. ;  but  later 


116  DISEASES   OF   THE   NERVOUS  SYSTEM. 

it  is  sleepy,  stupid,  lethargic ;  the  hypersesthesia  having  disap- 
peared, you  may  pinch  the  child  without  its  manifesting  much 
pain  or  annoyance.  After  observing  the  delirium,  maculae,  cephalic 
cry,  headache,  boat-shaped  abdomen,  flushings,  peculiarities  of 
pulse  and  respiration,  and  the  remissions  in  the  fever,  you  may 
imagine  that  there  is  no  possible  source  of  error.  Bear  in  mind, 
as  I  have  already  told  you,  that  it  is  not  always  possible  to  make 
a  diagnosis  at  first.  You  need  not  commit  yourself  by  giving  a 
positive  opinion,  but  should  endeavor,  by  proper  observation,  to 
arrive  at  correct  conclusions,  even  if  it  take  several  days  to  do  so. 
Also,  keep  well  in  mind  the  fact  that  these  signs  are  common  to 
different  diseases,  and  do  not  attach  too  much  importance  to  any 
isolated  symptom.  Judge  only  by  the  combination  of  manifesta- 
tions, sequence  of  events,  and  concurrence  of  conditions,  or  you 
will  be  led  into  error. 

The  third  stage  is  coma,  as  in  simple  meningitis.  The  pulse 
is  exceedingly  feeble  and  frequent,  too  frequent  to  be  counted. 
There  is  perspiration  and  a  clammy  feeling  of  the  skin,  the  pupils 
are  dilated,  and  we  have  the  symptoms  of  depression,  with  their 
ordinary  paralytic  phenomena.  Hammond  says,  "In  young  in- 
fants there  is  a  reduction  of  the  temperature  of  the  body  below 
the  normal  standard,  which  lasts  throughout  the  whole  of  this 
period."  Rogers  regarded  this  reduction,  preceded  as  it  is  by 
a  higher  temperature  and  followed  during  the  succeeding  stage 
by  another  elevation,  as  "pathognomonic  of  tubercular  menin- 
gitis." 

These  paralytic  phenomena  have  this  peculiarity,  that  they  are 
inclined  to  change,  so  that  we  may  first  have  a  paresis  or  a  hemi- 
plegia ;  strabismus  and  ptosis  may  occur  ;  or  first  one  group  of 
muscles  will  be  paralyzed,  to  be  followed  by  the  paralysis  of 
another,  and  then  again  the  paralysis  may  entirely  pass  away. 
Occasionally  there  are  convulsions,  absent  at  other  times ;  but  if 
they  are  present,  it  is  always  towards  the  termination  of  the  dis- 
ease, while  in  acute  idiopathic  meningitis  they  always  occur  at  the 
outset.  The  coma  finally  becomes  more  and  more  hopeless  and 
intense,  the  pulse  more  frequent  and  feeble,  the  skin  more  clammy 
and  moist,  the  urine  and  fseces  are  involuntarily  evacuated,  and 
death  ends  the  scene. 


TUBERCULAR   MENINGITIS.  117 


SPECIAL   SYMPTOMS   OF   TUBERCULAR   MENINGITIS. 

Having  described  the  general  symptoms  of  this  disease,  I  will 
now  refer  more  particularly  to  its  special  symptoms. 

The  premonitory  symptoms  of  the  period  of  invasion,  which,  as 
before  described,  while  progressive  is  yet  extraordinarily  gradual 
and  insidious,  present  a  previoug  history  of  ill  health  and  malaise ; 
the  child  complaining  of  numerous  ill-defined  disorders  concur- 
rently with  more  or  less  emaciation,  at  first  not  strikingly  evident, 
yet  eventually  unmistakable. 

Associated  with  this  is  a  moral  change,  sui  generis,  on  which  too 
great  stress  cannot  be  laid.  It  is  a  change  in  the  habits,  inclina- 
tions, and  temper  of  the  child.  Upon  this  point  we  cannot  too 
emphatically  claim  attention,  as  a  diagnostic  link  in  the  chain  of 
sequences.  The  changes  in  the  moral  and  in  the  physical  condi- 
tions progress  pari  passu. 

The  headache  often  exists  several  weeks  before  the  onset  of  the 
acute  symptoms,  which  may  be  due  to  the  deposit  of  tubercles  in 
the  pia  and  arachnoid,  a  condition  believed  to  exist  prior  to  the 
inflammatory  changes  of  these  last-mentioned  membranes. 

Headache  is  almost  invariably  present,  and  is  a  peculiarly  dis- 
tressing symptom,  continuous  in  the  main,  but  at  times  quali- 
fied by  more  or  less  marked  remissions  and  exacerbations.  The 
"hydrocephalic  cry"  v&  probably  the  result  of  intense  pain. 

Gowers  says,  "  In  rare  cases  meninigitis  runs  its  course  with 
little  or  no  pain.  This  is  especially  rare  in  tubercular  inflam- 
mation, but  not  uncommon  in  the  secondary  purulent  meninigitis 
of  septiccemia  and  in  the  simple  meningitis  of  some  other  blood- 
states."* 

Convulsions  occur  in  the  last  stages  of  tubercular  meningitis, 
and  very  seldom  at  the  onset,  as  in  acute  idiopathic  meningitis. 
They  are  usually  associated  with  septic  processes,  and  may  be 
unilateral  or  bilateral. 

Rigidity  of  the  muscles  of  the  neck  and  a  tendency  to  opisthot- 
onos are  more  frequently  met  with  in  tubercular  and  cerebro-spinal 
meningitis  than  in  any  other  of  its  varieties. 

Paresis  and  hemiplegia  become  more  particularly  manifest  in  the 

*  Italics  my  own. 


118  DISEASES    OF   THE    NERVOUS   SYSTEM. 

last  week  of  the  disease,  appearing  and  disappearing,  declining  and 
intensifying,  as  is  usual  with  symptoms  characterized  by  muta- 
bility, a  quality  essentially  pertaining  to  the  paralytic  phenomena 
of  tubercular  meningitis,  and  probably  dependent  upon  variations 
in  the  cerebral  circulation.  As  stated  before,  the  symjDtoms  of 
kinesodic  origin  are  more  prominently  developed  when  the  inflam- 
mation is  more  highly  pronounced  in  the  vicinity  of  the  central 
convolutions  and  paracentral  lobule. 

Paralysis  of  the  cranial  nerves  gives  rise  to  frequent  sympto- 
matic manifestations  of  tubercular  meningitis,  particularly  ptosis, 
strabismus,  and  facial  palsy,  inequality  of  the  pupil,  and  optic 
neuritis.  These  symptoms  are  most  frequently  encountered  at 
the  end  of  the  first  week. 

Towards  the  end  of  the  second  week  delirium  and  lethargy  deepen 
into  coma,  and  muscular  rigidity  is  increased ;  the  cranial- nerve 
disturbances  are  correspondingly  intensified,  and  so  are  the  local 
convulsions  and  local  paralyses. 

Disturbances  of  the  cesthesodic  zone  are  rarely  marked,  except, 
perhaps,  as  hypersesthesise. 

Aphasia  is  often  present  in  tubercular  meningitis,  which  is 
not  remarkable  when  we  consider  the  dominant  intensity  of  the 
inflammatory  changes  and  morbid  disturbances  in  the  fissure  of 
Sylvius,  where  the  deposit  and  consequent  irritation  of  tubercles 
are  greatest.  The  facial  palsy  is  not  very  considerable,  consisting 
principally  of  inequality  of  the  labial  commissures,  with  more  or 
less  inactivity  of  the  orbicularis  palpebrarum, — a  condition  not  to 
be  confounded  with  partial  ptosis  from  paralysis  of  the  levator  pal- 
pebrse,  due  to  palsy  of  the  third  pair.  In  all  brain  diseases  the 
palpebral  openings  should  be  carefully  examined  and  compared. 

The  aphasia  is  ataxic  or  motor  in  character,  but  may  be  asso- 
ciated also  with  the  amnesic  variety. 

Gowers  asserts  that  "  inequality  of  pupil  is  often  present  when 
other  ocular  symptoms  (including  neuritis)  are  absent." 

The  pulse  at  the  commencement  of  the  malady  is  increased  in 
frequency  and  correspondingly  diminished  in  volume ;  during  the 
second  week  it  becomes  cerebral  in  character,  being  often  reduced 
to  sixty,  fifty,  or  forty  per  minute.  Towards  the  termination  of 
the  disease  it  may  vary  from  one  hundred  and  thirty  to  one 
hundred  and  eighty  per  minute,  or  may  be  uncountable. 


TUBERCULAR   MENINGITIS.  119 

The  temperature  in  the  beginning  is  elevated  three  or  four 
degrees,  or  even  more,  as  time  passes,  sometimes  reaching  105°  or 
106°  F.  In  some  cases  it  falls  below  the  normal  shortly  before 
death.  In  purulent  meningitis  it  has  been  known  to  rise  as  high 
as  106°  or  108°  F.  It  has  been  asserted  that  in  some  exceptionally 
rare  cases  the  disease  runs  its  course  without  fever. 

Gowers  quotes  (from  Bokai)  that,  "  in  one  recorded  case,  on  the 
seventeenth  day  of  the  disease,  the  day  before  death,  the  temper- 
ature was  only  93°  F." 

Optic  neuritis  is  often  observable  about  the  end  of  the  first 
week. 

Towards  the  end  of  the  disease,  the  sphincters  often  become 
relaxed,  the  skin  cold  and  clammy,  and  the  eyes  glazed  and  not 
infrequently  covered  Avith  a  muco-purulent  secretion. 

The  auditory  nerve,  in  consequence  of  its  intimate  intracranial 
association  with  the  facial,  is  sometimes  affected. 

The  hypoglossal  nerve  is  rarely  affected ;  if  it  is,  the  tongue  vn\\ 
deviate  somewhat  on  protrusion. 

Sloughs  and  bed-sores  sometimes  occur. 

The  boat-shaped  abdomen,  alternations  of  flushings  and  pallor, 
remissions  in  the  fever,  "  hydrocephalic  cry,"  cerebral  maculae,  and 
disturbances  of  the  rhythm  of  the  pulse  and  respiration,  so  char- 
acteristic, have  been  sufficiently  described,  the  former  frequently 
corresponding  with  the  changes  in  the  latter. 

Embarrassment  of  the  respiration  is  a  pathognomonic  symptom 
of  tubercular  meningitis ;  it  is  a  rhythmical  disturbance  of  the 
respiratory  act,  and  corresponds  really  to  a  "  Cheyne-Stokes" 
respiration. 

ANATOMICAL,  APPEARANCES   OF    TUBEECULAR  MENINGITIS. 

Post-mortem  examination  reveals  the  presence  of  inflammation 
of  the  membranes, — namely,  the  pia  and  the  arachnoid.  In  ad- 
dition, tubercular  granulations  of  a  miliary  character  are  scattered 
here  and  there.  In  the  early  stages  they  are  very  small  and 
quite  transparent.  They  are  principally  seated  in  the  pia,  and 
can  be  felt  as  well  as  seen.  In  many  places  they  are  aggregated 
in  colonies.  They  afterwards  increase  in  size,  and  become  semi- 
opaque  in  appearance.  The  inflammation  of  the  membranes  is 
more  developed  at  the  base  of  the  brain,  especially  in  the  neigh- 


120  DISEASES   OF   THE   NERVOUS  SYSTEM. 

borhood  of  the  fissures  of  Sylvius  and  the  optic  chiasma.  There 
is  frequently  an  increase  of  cerebro-spinal  fluid,  particularly  at 
the  base. 

There  is  often  a  copious  exudation  of  lymph,  almost  semi- 
consistent,  in  some  instances  more  or  less  mingled  with  pus. 

As  stated  before,  there  is  frequently  ventricular  dropsy,  with 
an  inflammatory  thickening  of  the  ependyma,  accompanied  with 
more  or  less  softening  in  the  vicinity. 

The  granulations  are  composed  of  lymphoid  cells.  These 
bodies  are  usually  distributed  in  the  perivascular  spaces.  There 
is  often  an  optic  neuritis  by  extension  of  the  inflammation  along 
the  sheaths  of  the  optic  nerves. 

Some  dispute  has  arisen  among  eminent  authorities  as  to  whether 
the  gray  gelatinous  granulations  found  in  tubercular  meningi- 
tis are  tubercles  or  not.  Valleix,  Rilliet  and  Barthez,  Barrier, 
GrisoUe,  Meigs  and  Pepper,  and  others,  as  quoted  by  Hammond, 
regard  them  as  such,  Grisolle  expresses  himself  clearly  on  this 
point .  "  We  have  no  doubt,"  he  says,  "  that  these  granulations 
are  tubercles  in  a  rudimentary  state ;  for  we  have  many  times,  in 
the  same  subject,  followed  the  morbid  product  in  its  different 
phases  of  evolution  from  the  amorphous  condition  to  the  fully- 
developed  tubercle." 

Hammond,  again,  quotes  Robin  and  Bouchut  as  believing  in 
their  non-tubercular  nature,  in  which  opinion  he  does  not  sustain 
them. 

Dr.  Whytt,  of  Edinburgh,  was  probably  the  first  writer  (1768) 
who  published  systematic  observations  on  this  subject,  under  the 
caption  of  "  Hydrocephalus  Internus." 

It  is  conceded  by  most  writers  that  the  deposit  of  tubercles 
is  a  condition  prior  to  the  development  of  meningeal  inflamma- 
tion. 

It  is  also  generally  admitted  that  tubercles  in  these  cases  are 
usually  found  in  other  organs,  particularly  in  the  lungs  and  the 
mesentery. 

The  dropsical  effnsion  in  the  ventricles,  in  some  instances,  dis- 
tends all  the  ventricles. 

"  The  indications  of  occlusion  of  the  communication  between 
the  fourth  ventricle  and  the  surface,  already  mentioned,  are  more 
frequent  in  tubercular  than  in  simple  meningitis."     (Gowers.) 


TUBERCULAR   MEXIXGITIS.  121 

The  same  autliority  states  that  "  tubercles  may  be  found  in  the 
membranes  when  there  is  no  sign  of  inflammation,  in  cases  of 
general  tuberculosis,  and  they  may  be  accompanied  by  symptoms 
of  cerebral  disturbance  resembling  those  caused  by  inflammation." 

In  cases  of  tubercular  meningitis  the  bacilli  of  tubercle  are 
present. 

While  the  freight  of  authority  is  opposed  to  the  injection  of 
Koch's  lymph  for  general  diagnostic  purposes,  in  consequence  of 
the  dangerous  reactions  that  follow,  we  are  inclined  to  believe  that 
tubercular  meningitis  forms  an  exception  in  this  respect,  because, 
of  the  jeopardy  in  which  the  patient's  life  is  placed,  and  that 
objections  of  this  kind  would  be  more  than  counterbalanced  by 
the  results  and  chances  of  these  injections. 

"  It  is  claimed  that  the  descending  horn  of  the  lateral  ventricle 
is  particularly  liable  to  become  over-distended  in  tubercular  men- 
ingitis. The  exudation  into  the  ventricles  may  be  purulent  in 
rare  instances.  As  a  rule,  it  consists  of  serous  fluid  which  is  more 
or  less  turbid  from  an  admixture  of  white  blood-corpuscles  and 
epithelium.  Tubercles  may  be  often  detected  in  the  ependyma, 
and  along  the  vessels  of  the  choroid  plexus."     (Ranney.) 

The  morbid  anatomy  of  tubercular  meningitis  may  be  divided 
as  follows  :  (1)  tubercular  infiltration  ;  (2)  an  inflammatory  exu- 
dation in  the  meshes  of  the  pia ;  (3)  ventricular  dropsy. 

The  favorite  site  of  the  miliary  tubercular  deposits  in  this  dis- 
ease is  at  the  base  of  the  brain ;  they  are  most  frequently  encoun- 
tered at  the  bifurcations  of  the  blood-vessels,  in  the  neighborhood 
of  the  Sylvian  fissures  and  of  the  optic  chiasma,  and  in  the  region 
of  the  circle  of  Willis. 

Gowers  and  Ranney  have  frequently  observed  miliary  deposits 
in  the  neighborhood  of  the  longitudinal  fissure. 

According  to  the  Meroredi  Medical,  ]\I.  Jean  Charcot  and  M. 
Souques,  from  investigations  in  a  nimiber  of  cases  of  phthisis 
where  the  brain  had  become  secondarily  involved,  have  found  that 
the  commonest  seat  of  attack  of  the  tubercular  process  is  the 
paracentral  lobule.  The  authors  are  of  the  opinion  that  this  is 
due  to  the  peculiar  circulatory  arrangements  in  and  around  this 
region.* 

*  New  York  Medical  Journal,  August  1,  1891. 


122  DISEASES   OF    THE   NERVOUS   SYSTEM. 

DIAGNOSIS. 

What  are  the  diseases  with  which  tubercular  meningitis  may  be 
confounded  ?  I  may  mention,  first,  bilious  remittent  fevei\  This 
we  can  readily  diagnosticate  by  giving  quinine,  a  specific  for  this 
disease.  If  your  are  doubtful  of  your  diagnosis,  do  not  hesitate  to 
administer  this  drug  freely  and  boldly  ;  for  in  cerebral  affections 
it  is  best  to  give  it  in  large  and  sedative  doses,  in  preference  to 
smaller  ones,  which  only  irritate  and  produce  no  compensating 
beneficial  effects. 

Sometimes  it  becomes  difficult  to  distinguish  tubercular  menin- 
gitis from  typhoid  fever,  because  the  symptoms  of  the  latter,  es- 
pecially those  of  a  cerebral  character,  often  bear  a  great  similarity 
to  those  of  the  former  disease.  In  children  the  enteric  symptoms 
— diarrhoea  and  tympanites — are  often  absent,  while  the  brain- 
symptoms  are  very  prominent.  But  here  you  must  remember  the 
pathognomonic  symptom,  which  is  the  peculiar  disturbance  in  the 
respiration,  always  present  in  tubercular  meningitis,  never  in 
typhoid  fever.  It  is  important  to  diagnosticate  correctly  in  this 
respect,  as  typhoid  fever  is  not  often  fatal  in  children,  W'hile 
tubercular  meningitis  is  always  an  "  implacable  affection." 

There  is  another  condition  to  be  considered  in  this  connection, 
the  hydroeephaloid  of  Marshall  Hall.  This  is  but  another  name 
applied  to  general  anaemia  of  the  brain,  causing  cerebral  symp- 
toms, which  is  developed  in  children  after  protracted  exhaustive 
diseases,  especially  bowel-complaints  lasting  for  a  long  time.  It 
is  very  often  the  result  of  cholera  infantum.  In  this  affection, 
when  the  diarrhoea  exists,  the  first  thing  in  order  is  to  check  its 
progress.  We  should  give  brandy,  and  even  ammonia,  if  the 
system  will  bear  it ;  but  we  should  inevitably  produce  disastrous 
and  fatal  consequences  if  we  were  to  mistake  it  for  congestion  or 
inflammation  and  treat  accordingly  these  hydroeephaloid  symp- 
toms, w^hich  bear  a  striking  analogy  to  the  phenomena  presented 
during  the  course  of  the  meningeal  affections  we  have  just  studied. 
On  the  contrary,  gentlemen,  it  is  under  such  circumstances  that 
you  must  energetically  sustain  the  vital  powers.  In  this  manner 
a  cure  may  be  effected ;  while,  if  these  measures  be  neglected, 
death  will  surely  follow.  This  proves  the  validity  of  an  assertion 
made  in  a  former  lecture,  of  the  similarity  of  the  symptoms  of 


TUBERCULAR   MEXIXGITIS.  123 

cerebral  anaemia  and  cerebral  hyperaemia.  In  all  these  forms  of 
meningitis  there  is  an  anaemia  of  the  capillary  vessels,  produced 
towards  the  termination  of  the  malady.  The  pathological  law 
which  I  have  so  often  given  you  can  be  once  more  ajDplied  in 
these  affections, — I  mean  the  state  of  depression  which  follows 
the  primary  one  of  irritation.  In  complete  anaemia  the  aboli- 
tion of  the  functions  is  absolute,  and  only  the  symptoms  of 
depression  are  evident.  But  in  partial  anaemia  we  have  the 
symptoms  of  excitation  preceding  those  of  depression ;  and  this 
is  exactly  what  happens  in  meningitis. 

In  conclusion,  allow  me  to  state  that  the  prognosis  is  of  the 
utmost  gravity  :  death  is  the  usual  termination. 

As  to  treatment,  there  is  none  which  has  ever  been  successful. 
Notwithstanding  this,  you  should  spare  no  efforts  to  save  the  life 
of  your  patient ;  and  I  therefore  recommend  to  you,  as  indorsed 
by  the  highest  authorities,  the  iodide  of  potassium,  freely  ad- 
ministered in  combination  with  the  bromide  of  potassium.  Use 
counter-irritants,  and  pustulate  the  scalp  with  croton  oil.  Do  not 
lose  sight  of  the  hygienic  treatment.  Tonics,  beef  tea,  etc.,  must 
never  be  neglected.  In  the  last  stages  you  may  give  stimulants. 
During  the  prodromic  stage  cod-liver  oil  and  the  hypophosphites 
should  be  administered  in  all  cases. 

Regarding  ventricular-surgery  in  tubercular  meningitis,  I  quote 
from  a  recent  able  article  by  Dr.  L.  Bremer,  of  St.  Louis,  "  An 
Outline  of  Cerebral  Surgery,"  St.  Louis  Ifedical  Review,  October, 
1891  :  "  Puncture  of  the  ventricles  for  acute  hydrocephalus  is 
also  looked  upon  by  most  brain-surgeons  with  disfavor,  because, 
it  is  claimed,  it  represents  only  a  localization  of  miliary  tubercu- 
losis. But  whether  there  are  not  cases  of  acute  tubercular  hydro- 
cephalus which  might  be  saved  by  timely  surgical  interference 
from  almost  absolutely  certain  death,  is  still  an  open  question.  If 
we  bear  in  mind  the  surprising  effect  of  the  opening  of  the  ab- 
domen in  tubercular  peritonitis,  and,  furthermore,  that  crops  of 
miliary  tubercles  have  been  observed  to  appear  and  disappear 
in  the  larynx,  we  must  look  upon  miliary  tuberculosis  as  being 
curable,  perhaps  more  curable  than  any  other  form  of  the  tuber- 
cular processes,  and  we  certainly  have  no  right  yet  to  condemn  an 
operation  for  a  meningitis  which  is  done  on  the  same  principle 
as  that  for  a  peritonitis." 


LECTURE  yil. 

CEREBEO-SPrN"AIi   MEISTNGITIS. 

Anatomical  Characters — Its  Nature — An  Essential  Fever — Malignant  Scarlet  Fever — • 
Malarial  Fevers — Three  Forms  :  Simple,  Fulminant,  and  Pui-puric — Clinical  History 
— First  Form — Symptoms — Brain,  Spinal,  and  General :  Chills  and  Fever,  Vomiting, 
Pain,  Decubitus  —  Second  Form  —  Third  Form  —  Pieabsorbent  Fever  —  Death  from 
Asthenia  or  Coma — Generalities — Pathological  Anatomy — Prognosis — Treatment — 
Hygiene — Morphine  for  Rachialgia — Iodide  and  Bromide  of  Potassium,  Fluid  Ex- 
tract of  Ergot,  Belladonna,  Quinine,  Salicylate  and  Benzoate  of  Sodium. 

Ge:n'tlemes', — In  to-night's  lecture  I  propose  to  treat  of  an 
interesting  affection,  generally  prevailing  epidemically,  and  very 
rarely  sporadically, — an  exceedingly  fatal  disease,  with  which  phy- 
sicians find  it  difficult  to  contend.  Those  who  fully  appreciate  its 
nature  and  are  candid  Nvill  readily  admit  that  they  dread  its  occur- 
rence and  have  little  or  no  control  over  its  progress.  This  dis- 
ease is  cerebro-spinal  meningitis,  sometimes  denominated  "  spotted 
fever,"  and  known  by  many  other  names, — the  consideration  of 
which  need  not  detain  us. 

Cerebro-spinal  meningitis  is  an  inflammation  of  the  membranes 
of  the  hrain  and  of  the  spinal  cord.  Hence'  the  distinction  is  easy 
between  this  affection  and  affections  involving  only  the  membranes 
of  the  brain.  It  is  really  a  cerebral  meningitis  plus  a  spinal 
meningitis,  the  brain  and  the  spinal  cord  being  both  enveloped 
by  the  same  membranes. 

As  regards  its  nature,  several  conflicting  opinions  exist.  Some 
contend  that  it  is  essentially  a  disease  of  the  nervous  system ; 
others,  that  it  is  malarial  in  origin ;  and  still  others,  that  it  belongs 
to  the  essential  fevers.  To  discuss  this  question  fully  would  re- 
quire much  time,  and,  after  all,  perhaps  we  should  not  arrive  at  a 
satisfactory  conclusion.  I  do  not  think  it  a  disease  of  the  nervous 
system,  any  more  than  I  think  that  typhoid  fever  should  be  ranked 
under  such  a  classification.  I  believe,  with  most  neuro-patholo- 
124 


CEREBRO-SPINAL    MENINGITIS.  125 

gists,  that  it  is  the  result  of  a  blood-poison, — actually  an  essential 
fever,  whose  whole  force  and  violence  are  expended  uj^on  the 
nervous  system,  not  unlike  the  materies  morhi  existing  in  typhoid 
fever,  which  attacks  Peyer's  glands,  causing  prominence  of  the 
abdominal  symptoms,  because  the  principal  outburst  of  the  storm 
is  spent  upon  those  organs.  Hence,  as  we  do  not  know  the  actual 
character  of  typhoid  fever,  it  miglit  be  better,  with  Dr.  Wood, 
to  call  it  an  enteric  fever.  It  is  highly  probable  that  just  as  a  par- 
ticular materies  morbi  produces  enteric  fever,  so  does  the  blood- 
poison  in  cerebro- spinal  meningitis  indiiice  inflammation  of  the 
cerebro-spinal  coverings. 

Cerebro-spinal  meningitis  has  been  held  by  some  to  be  merely 
a  variety  of  malignant  scarlet  fever.  Such  a  theory  scarcely 
needs  refutation ;  almost  all  authors  agree  that  cerebro-spinal 
meningitis  possesses  nothing  in  common  with  the  exanthematous 
or  eruptive  fevers.  The  reason  for  my  not  believing  it  to  have 
any  relationship  to  malarial  fever  is,  that  quinine,  which  possesses 
such  remarkably  specific  powers  in,  and  is  the  best  and  most  re- 
liable of  all  antidotes  to,  malarial  toxaemia,  is  utterly  powerless  to 
arrest  or  even  influence  its  course.  I  have  given  it  myself,  in 
large  and  bold  doses,  and,  notwithstanding  my  firm  belief  in  its 
efficacy  and  extraordinary  powers  in  most  febrile  complaints,  I 
must  confess  its  total  failure  in  my  hands  to  control  this  disease 
in  the  slightest  degree ;  and  almost  all  other  medicines  with  which 
I  have  tried  to  check  the  devastations  of  this  dreadful  scouroje 
have  likewise  produced  little  or  no  satisfactory  result.  In  refer- 
ence to  the  question  of  its  being  a  kind  of  "  cerebral  t}^phus,"  I 
can  safely  assert  that  cerebro-spinal  meningitis  has,  in  my  opinion, 
no  relationship  whatever  to  typhus.  There  may  be,  it  is  true, 
a  similarity  between  some  of  the  clinical  phenomena  of  both  dis- 
eases ;  yet  in  reviewing  its  history  we  must  come  to  the  conclusion 
that  cerebro-spinal  meniagitis  is  not  a  form  of  typhus  fever.  Ty- 
phus is  a  very  contagious  disease, — far  more  so  than  cerebro-spinal 
meningitis.  Neither  is  typhus  a  disease  of  such  short  duration, 
nor  does  it  uniformly  involve  the  cerebro-spinal  meninges.  In 
the  cerebro-spinal  form  of  meningitis  there  are  marked  symptoms 
of  spinal  origin,  although  there  are  also  purely  intracranial  ones ; 
but  the  former  are  never  present  in  typhus.  Neither  is  there  any 
similarity  between  the  eruptions  of  the  two  diseases.     Cerebro- 


126  DISEASES   OF   THE   NERVOUS   SYSTEM. 

spinal  meningitis  is,  consequently,  in  all  probability  a  disease  sui 
generis,  and  should  be  grouped  with  the  essential  fevers. 

You  will  perhaps  ask  yourselves,  If  this  be  the  case,  why  speak 
of  it  in  connection  with  diseases  of  the  nervous  system  ?  I  simply 
do  so  as  a  matter  of  convenience  and  custom.  Some  of  its  pathog- 
nomonic symptoms  are  entirely  referable  to  the  nervous  system. 
I  think  it  advisable,  therefore,  to  speak  of  it  at  the  present  moment, 
in  order  to  differentiate  the  disease  from  other  forms  of  menin- 
gitis ;  my  chief  idea  being  to  give  you  a  proper  conception  of  its 
peculiarities. 

We  must  next  consider  the  principal  symptoms  of  this  affection. 
As  regards  their  classification,  I  believe,  with  Russell  Reynolds, 
that  there  are  three  forms  or  varieties  of  cerebro-spinal  meningitis. 
I  shall  not  describe  them  at  length,  but  shall  merely  review  their 
principal  features.  The  first  is  the  simple  or  ordinary  variety ;  the 
second,  the  fulminant ;  and  the  third,  the  purpuric. 

The  ordinary  variety,  like  the  others,  rarely  occurs  sporadically, 
the  disease  being  generally  epidemic,  and  often  devastating  whole 
communities.  It  occurs  mainly  in  crowded,  unhealthy,  ill-venti- 
lated places,  or  where  hygienic  requirements  are  neglected.  This 
often  happens  in  prisons,  camps,  workhouses,  and  hospitals. 
There  is  perhaps  a  short  period  of  invasion,  marked  by  general 
malaise,  and,  in  abortive  cases,  by  headache  and  constipation ;  but 
I  believe  the  disease  rarely  aborts,  and  the  patient  but  too  often 
dies.  The  mortality  is  always  greatest  during  the  early  part  of 
an  epidemic.  This  is  usually  the  rule  under  such  circumstances, 
the  greatest  malignancy  generally  occurring  in  the  earlier  cases, 
and  thus  spending  itself;  and,  no  matter  how  great  your  care  or 
how  unceasing  and  earnest  your  efforts,  they  will  at  this  period 
usually  prove  futile.  During  its  prevalence  you  will  be  on  the 
alert :  as  during  epidemic  visitations  of  variola,  when  everybody 
grows  alarmed  at  the  appearance  of  no  matter  what  kind  of  an 
eruption,  and  backache,  or  as  in  scarlatina,  when  the  slightest 
throat-trouble  causes  the  greatest  anxiety,  so  during  the  existence 
in  the  community  of  cerebro-spinal  meningitis  the  least  pain  in 
the  occipital  region  gives  occasion  for  the  most  serious  appre- 
hension. 

The  phenomena  of  the  simple  form  of  cerebro-spinal  meningitis 
are  first  chill,  which  is  followed  hy  fever ;  then  more  or  less  vomit- 


CEREBRO-SPINAL   MENINGITIS.  127 

ing,  accompanied  by  violent  jpain  in  the  head,  nucha,  and  back,  and 
delir'mm. 

In  order  to  recognize  an  acquaintance,  we  ordinarily  endeavor 
to  recall  the  peculiar  appearance  and  general  conformation  of  his 
features,  not  the  particular  form  or  character  of  any  single  linea- 
ment of  his  countenance,  but  the  special  combination  which  char- 
acterizes his  physiognomy.  So  it  is  in  disease,  the  peculiarities 
of  which  are  not  always  represented  by  one  symptom,  but  by  a  con- 
currence of  many,  and  also  by  their  peculiar  grouping  and  arrange- 
ment. In  cerebro-spinal  meningitis,  therefore,  we  consider,  first, 
the  epidemie  prevalence  of  the  disease,  the  initiatory  chill  and  fever, 
the  vomiting,  the  delirium,  the  pain  in  the  nape  of  the  neck  and  in 
the  spinal  region,  and  the  general  cutaneous  hypercesthesia. 

Vomiting  is  always  a  marked,  persistent,  and  obstinate  symp- 
tom. The  pain  in  the  nucha  is  violent  and  enduring.  One  of 
the  important  peculiarities  of  the  clinical  phenomena  is,  that  the 
pain  in  the  spinal  region  is  intensely  severe.  It  is  lancinating, 
— darting  to  the  four  extremities  of  the  body,  its  violence  being 
greatly  aggravated  by  the  least  movement ;  and  hence  the  decu- 
bitus of  the  patient  is  very  peculiar,  and  sometimes  causes  the 
meningitis  to  be  mistaken  for  rheumatism,  especially  as  the  hyper- 
sesthesia  may  bo  misinterpreted. 

In  cerebro-spinal  meningitis  we  have  brain-symptoms,  the 
meninges  of  the  brain  being  involved  ;  and  we  therefore  find  the 
violent  pain  in  the  head,  with  the  existence  of  prominent  delirium. 
Among  the  other  brain-symptoms  are  vomiting,  insomnia,  con- 
stipation, and  contraction  of  the  pupils,  which  afterwards  dilate. 
The  spinal  symptoms  are  the  lancinating  lumbar  and  sacral  pains, 
aggravated  by  every  movement,  and  accompanied  by  more  or  less 
spasm,  mostly  of  the  muscles  of  the  neck,  thus  fixing  the  head 
backwards  on  the  spine.  In  some  cases  the  spasmodic  contraction 
is  so  extensive  as  to  draw  the  whole  body  violently  and  firmly 
backwards,  producing  opisthotonos :  usually  the  spasm  is  limited  to 
the  nuchal  region. 

The  general  symptoms  are  fever,  with  a  temperature  varying 
from  103°-4°  to  106°-7°  F.,  more  or  less  constipation,  sometimes 
diarrhoea,  anorexia,  prostration  of  the  vital  powers,  due  to  the 
implication  of  the  nervous  centres,  and  insomnia,  or,  in  some  cases, 
stupor.     There  is  often  an  herpetic  eruption  in  the  neighborhood 


128  DISEASES   OF   THE   NERVOUS  SYSTEM. 

of  the  lips,  and  eccliymoses  on  the  body,  giving  the  disease  the 
name  of  "  spotted  fever."  These  symptoms  constitute  the  ordinary 
form  of  cerebro-spinal  meningitis.  Of  course  they  vary  with  dif- 
ferent epidemics ;  and  so  at  times  the  eruption  will  be  greater  or 
less,  or  even  absent ;  the  disease  also  differing  in  violence,  intensity, 
and  duration. 

The  second  is  the  fulminant  t}^e.  This  means  the  "  thunder- 
ing" form,  and  in  truth  it  is  also  a  very  lethal  type  of  the  disease. 
Its  malignity  is  so  great  that  it  has  proved  fatal  in  five  hours.  If 
a  blood-poison  is  of  sufficient  virulence  to  produce  such  terrible 
results,  what  can  a  physician  accomplish  in  his  efforts  to  oppose  its 
progress  ?  He  can  achieve  nothing.  What  constitute  the  pecu- 
liarities of  this  form  ?  Have  you  ever  seen  the  stage  of  collapse 
of  epidemic  cholera,  the  algid  state,  as  it  is  called  ?  If  you  have, 
you  will  remember  the  ghastly  pallor,  the  shrunken  condition 
and  clammy  coldness  of  the  skin,  the  pulselessness  and  general 
prostration,  the  cyanotic  appearance  of  the  mucous  membranes, 
and  the  rapid  sinking  of  the  vital  powers.  These  phenomena 
are  also  seen  in  the  fulminant  form  of  cerebro-spinal  meningitis, 
with  apoplectic  phenomena  in  addition.  You  thus  have  the  ap- 
pearances of  the  algid  state  of  cholera,  plus  coma.  There  is  little 
possibility  of  reaction,  and  at  your  first  visit  your  patient  is  often 
moribund, — at  the  second,  dead. 

The  third  form  is  the  purpuric.  This  form  occurs  as  a  combina- 
tion either  of  the  first  and  the  second,  or  of  the  first  Avith  purpuric 
symptoms,  in  consequence  of  extensive  and  profound  blood-poison- 
ing, the  result  of  dyscrasia  or  true  necrsemia.  There  is  a  tendency 
to  extravasation  of  blood  in  the  subcutaneous  and  submucous  tis- 
sues ;  the  capillaries,  friable  from  want  of  tonicity,  rupture ;  hemor- 
rhage follows,  and  petechise  appear.  No  matter  what  combination 
of  symptoms  accompany  this  variety,  there  is  an  intense,  malig- 
nant blood-poisoning,  a  necraemia,  and  a  conjoint  appearance  of 
spots  and  blotches  of  a  purpuric  hue  upon  the  surface  of  the  body. 
There  is  another  remarkable  fact  in  regard  to  the  symp- 
tomatology of  this  disease,  referred  to  by  Ziemssen.  Patients  who 
do  not  die  during  the  first  or  second  week  of  the  attack  are  not 
entirely  free  from  danger.  Very  often  a  fever  is  developed,  called 
the  "reabsorbent  fever,"  which  is  a  pysemic  condition,  induced 
by  the  absorption  of  peccant  matter.     In  this  disease,  as  well  as 


CEREBRO-SPINAL   MENINGITIS.  129 

in  simple  cerebral  meningitis,  a  sero-purulent  exudation  collects 
in  the  subaracbnoidean  spaces,  and  at  the  base  of  the  brain,  causing 
an  impairment  in  the  functions  of  the  nerves  of  special  sense. 

After  the  primary  fever  has  disappeared,  the  reabsorbent  fever 
develops  during  convalescence.  An  absorption  of  the  exudations 
occurs ;  and  if  the  resulting  pyaemia  be  not  fatal,  the  patient 
evinces  signs  of  a  commencing  protracted  recovery,  though  still 
having  one  more  danger  to  incur, — that  of  a  marasmus,  not  unlike 
tabes  mesenterica.  The  nervous  centres  presiding  over  the  func- 
tions of  nutrition  are  probably  at  fault,  damaged  by  the  violence 
of  the  acute  stage ;  a  pernicious  diarrhoea  and  progressive  wasting 
soon  reduce  the  patient,  in  spite  of  beef  tea,  wine,  and  tonics,  to 
a  mere  skeleton.  Finally,  death  by  asthenia  occurs  ;  although  at 
earlier  periods  of  the  disease  it  may  be  from  coma. 

While  we  have  considered  the  nature  and  etiology  of  this 
malady,  some  little  remains  to  be  said  of  its  pathology  or  patho- 
logical anatomy.  I  believe  that  cerebro-spinal  meningitis  is  pri- 
marily a  disease  of  the  blood,  with  inflammation  of  the  pia  and 
arachnoid  of  the  cerebrmn  and  medulla  spinalis,  resulting  from 
toxaemia,  and  attended  by  an  effusion  of  serum,  lymph,  and  pus. 
If  death  is  produced  by  necrcemia,  no  trace  of  meningeal  inflam- 
mation is  found,  because  there  has  not  been  sufficient  time  for  the 
inflammatory  condition  to  produce  the  transudation. 

In  view  of  what  has  been  said,  you  may  readily  infer  the  prog- 
nosis :  it  is  of  very  grave  import,  and  experienced  physicians  fear 
to  encounter  this  dread  disease.  I  hesitate  to  consider  its  treat- 
ment, having  tried  almost  everything  with  but  slight  beneficial 
results.  I  have  lost  many  cases,  some  dying  in  spite  of  every 
effort  to  save  them.  Others  recover  almost  unaccountably.  Of 
course,  on  reference  to  your  books  you  will  find  modes  of  treat- 
ment detailed  ad  infinitum  ;  but  after  testing  their  efliciency  at  the 
bedside  and  observing  the  results,  your  faith  in  medication  will 
probably  be  almost  completely  shattered.  Try  for  yourselves,  and 
profit  by  your  o^vn  experience.  I  doubt  if  we  shall  ever  be  able 
to  make  great  progress  in  mastering  epidemics.  In  all  cases,  be 
guided  by  your  experience,  your  convictions,  and  your  earnest 
desire  to  achieve  your  utmost.  I  do  not  wish  to  trammel  your 
memories  with  a  catalogue  of  therapeutical  resources,  as  I  have 
found  no  satisfactory  result  from  any  medication  in  the  cases  which 

9 


130  nSEASES    OF    THE    NERVOUS   SYSTEM. 

have  fallen  under  my  observation.  Keep  up  nutrition  and  sustain 
the  vital  powers.  During  rachialgia  you  may  use  morphine  hypo- 
dermically,  taking  care  not  to  give  too  large  a  dose.  You  might 
administer  iodide  and  bromide  of  potassium  and  fluid  extract  of 
ergot ;  the  two  latter,  by  acting  on  the  vaso-motor  nerves,  may  con- 
trol the  hypersemia  of  the  meninges.  Belladonna,  cannabis  Indica, 
quinine  salicylate  and  benzoate  of  sodium,  counter-irritants,  etc., 
have  all  been  recommended.  I  have  only  to  add  in  regard  to 
remedies  that  their  number  is  generally  in  direct  proportion  to 
the  hopelessness  of  the  affection.  Their  multiplicity  corresponds 
with  their  inefficiency. 

GENERALITIES. 

Cerebro-spinal  meningitis  has  especially  prevailed  in  the  United 
States  and  in  Europe,  notably  in  Sweden,  Germany,  France,  and 
Ireland.  It  is  a  disease  of  all  ages ;  in  some  epidemics  children 
have  been  more  frequently  attacked.  It  is  more  prevalent  in  the 
first  two  decades  of  life.  Winter  and  spring  are  the  periods 
during  Avhich  its  epidemic  influence  is  most  felt.  Though  very 
probably  an  infectious  disease,  it  is  in  no  sense  contagious,  nor  does 
one  attack  afford  protection  from  another. 

As  in  all  acute  affections,  a  rigor  or  chill  may  constitute  an  in- 
itiatory symptom.  Vomiting  and  headache  are  very  prominent 
symptoms  after  the  chill,  and  are  usually  accompanied  with  intense 
rachialgia.  The  headache  is  always  very  severe,  and  often  con- 
stant. The  hypersesthesise  of  the  skin  and  of  the  nerves  of  special 
sense  are  very  acute.  Delirium  and  headache  are  concomitant. 
The  rachialgia  is  accompanied  by  erratic  pains  in  various  muscles, 
is  increased  by  movement,  and  may  radiate  in  various  directions, 
especially  towards  the  loins  and  limbs.  Rigidity  of  the  muscles 
of  the  neck  and  back  and  retraction  of  the  head  are  eminently 
characteristic  features.  Movement  or  flexion  of  the  neck  is  ex- 
tremely painful.  Trismus  has  been  noticed  in  a  few  cases.  Con- 
vulsions are  noticed  at  times,  but  are  not  limited  to  any  particular 
stage  of  the  disease.  The  abdomen  is  sometimes  retracted,  and  the 
legs  may  be  drawn  up. 

"  Cerebro-spinal  fever  may  during  an  epidemic  complicate  other 
acute  maladies,  and  mix  its  symptoms  curiously  with  them.  With 
an  attack  of  this  disease  the  trouble  does  not  pass  off,  for  it  may 


CEREBRO-SPINAL   MENINGITIS.  131 

leave  behind  it  all  kinds  of  want  of  power  and  local  palsies,  be- 
sides derangements  of  vision,  'permanent  deafness,  impaired  intel- 
ligence, epilepsy,  persistent  headache,  chronic  meningitis,  which 
may  be  its  cause,  and  chronic  hydrocephalus."     (Da  Costa.) 

The  blood-changes  are  very  rapid  and  intense  in  cerebro-spinal 
meningitis.  The  necrsemia,  the  conspicuous  head-symptoms,  and 
the  peculiar  eruptions  are  features  of  this  affection  comparable 
with  those  of  typhus  fever.  In  cerebro-spinal  fever,  however, 
the  blood-deterioration  is  more  intensified  and  more  quickly  ac- 
complished. The  delirium  is  less,  the  fever  is  not  so  high,  and 
the  duration  of  the  disease  is  shorter. 

Da  Costa  says,  "  In  an  autopsy  on  a  child  that  died  in  twenty- 
four  hours,  I  found  the  blood  diffluent  and  black ;  in  an  adult 
patient  who  had  been  sick  but  two  days,  I  detected  blowing 
sounds  in  the  heart,  evidently  of  blood-origin.  The  poisoned 
blood  unquestionably  gives  rise  to  many  of  the  nervous  symptoms, 
and  it  is  on  the  blood  and  the  nervous  centres  that  the  poison 
mainly  acts." 

The  temperature  and  pulse  vary  much  :  the  former  may  rise 
from  104°  to  106°  F. ;  the  latter,  from  one  hundred  and  twenty 
to  one  hundred  and  fifty  beats  to  the  minute. 

In  view  of  the  skin-eruptions,  the  disease  in  this  country  has 
sometimes  been  called  "  spotted  fever"  Purpura,  herpes,  erythema, 
and  urticaria  are  frequently  encountered. 

Paralysis  of  the  cranial  nerves,  deviation  of  the  eyes  to  one 
side,  inequality  of  the  pupils,  and  strabismus  are  not  infrequent. 
Conjunctivitis,  optic  neuritis,  and  ulceration  of  the  cornea  may 
be  observed.  As  in  acute  idiopathic  meningitis,  the  pupils  are 
primarily  contracted  and  in  the  later  stages  dilated. 

Permanent  deafness  and  blindness  are  not  infrequent  among 
the  sequelae. 

In  character  and  duration  the  disease  presents  great  variations. 
Gowers  states  that  "  in  the  most  acute  cases  the  patient  quickly  be- 
comes comatose,  and  dies  at  the  end  of  one  or  two  days,  sometimes 
even  in  five  or  six  hours  from  the  onset."  The  acute  form  has 
been  termed  fulminant.  On  the  other  hand,  mild  cases  sometimes 
occur,  where  the  symptoms  are  headache,  pain  in  the  back,  and 
slight  rigidity  of  the  neck-muscles, — a  form  that  has  been  termed, 
somewhat  inaptly,  abortive. 


132  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  mortalitj  varies  in  diflferent  epidemics :  it  is  sometimes 
very  high. 

Pneumonia  and  broncliitis  are  occasional  complications.  Ar- 
thritis is  sometimes  another  complication,  and  should  not  be 
confounded  with  rheumatism,  "  as  the  head-symptoms,  the  state 
of  the  muscles  of  the  neck,  and  the  dissimilar  course  of  the  mal- 
ady soon  clear  up  the  diagnosis."     (Da  Costa.) 

The  disease  has  sometimes  been  confounded  with  scarlatina. 
"  An  extremely  rapid  pulse  *  would  be  in  favor  of  the  view  of  the 
case  being  scarlatina."     (Da  Costa.) 

In  some  cases  there  is  persistent  vomiting. 

The  characteristic  eruption  is  described  as  follows  by  Da  Costa  : 
"  The  cutaneous  surface  is  frequently  spotted  with  a  red  eruption, 
erythematous  and  roseolous, — an  eruption  which  often  becomes 
brownish  and  then  for  the  most  part  rapidly  petechial,  and  which 
is  wholly  uninfluenced  by  pressure ;  or  the  purple  spots  may  be 
seen  from  the  start." 

Ziemssen  states  "that  the  high  temperatures  are  often  inter- 
rupted by  long-continued  normal  temperatures." 

Lung-troubles  may  predominate  much  more  in  some  epidemics 
than  in  others. 

"  Uraemia  may  cause  muscular  rigidity,  convulsions,  and  coma, 
thus  occasionally  giving  rise  to  symptoms  somewhat  like  those  of 
cerebro-spinal  meningitis  (]\Iurchison) ;  but  the  temperature  is 
normal,  and  other  symptoms  of  each  malady  are  usually  recog- 
nizable. It  must  be  remembered  that  in  children  retraction  of 
the  head  may  occur  from  rheumatic  affection  of  the  muscles  and 
other  causes."     (Gowers.) 

"  A  considerable  diagnostic  difficulty  is  presented  by  cases  in 
which  the  meningitis  runs  an  almost  latent  course.  It  is  some- 
times found,  after  death,  in  cases  of  pneumonia  in  which  it  was 
not  suspected  during  life,  the  headache  and  deliriiun  having  been 
ascribed  to  the  pulmonary  malady.  Unequivocal  symptoms  -of 
cerebral  mischief,  however  sliglit  they  may  be,  should  always 
receive  attention  in  this  disease. 

"  General  hypersesthesia  sometimes  first  suggests  the  presence 
of  more  than  the  lung-disease."     (Gowers.) 

*  Italics  my  own. 


CEREBEO-SPINAL   MENINGITIS.  133 

ANATOMICAL  APPEARANCES. 

There  is  intense  opacity  and  congestion  of  the  pia  of  the  brain 
and  cord,  and  sometimes  the  latter  also  is  inflamed.  The  ventri- 
cles of  the  brain  are  sometimes  distended  with  fluid,  or  even  with 
pus.  The  ependyma  is  frequently  involved  in  the  inflammatory 
changes.  The  brain  contains  foci  of  softening,  purulent  collec- 
tions, and  minute  hemorrhages.  Exudations  of  lympli,  with 
depots  of  pus,  are  not  infrequently  found  in  the  membranes, 
which  are  often  thickened  and  in  places  adherent.  The  microscope 
sometimes  shows  lymphoid  cells  along  the  course  of  the  vessels. 

"The  proved  dependence  of  many  acute  specific  diseases  on 
micro-organisms  has  suggested  the  probability  that  epidemic 
meningitis  is  due  to  a  similar  cause."     (Ziemssen.) 

BACTERIOLOGY   OF   EPIDEMIC  CEREBRO-SPINAL   MENINGITIS. 

"  Several  interesting  studies  of  this  subject  from  a  bacteriologi- 
cal stand-point  have  been  recently  made,  of  which  that  by  Adenot 
is  perhaps  the  most  exhaustive.  His  conclusions  are  :  1.  Several 
varieties  of  microbes  have  already  been  found  in  the  meningeal 
exudates.  2.  The  kinds  thus  far  found  in  meningitis  are  :  a,  the 
pneumococcus ;  6,  the  streptococcus  pyogenes ;  c,  the  intra-cellular 
micrococcus  of  Weichselbaum  ;  d,  the  probable  bacillus  of  typhoid 
fever ;  e,  the  probable  staphylococcus  pyogenes ;  /,  the  pneumo- 
bacillus  of  Friedlander ;  g,  undetermined  microbes.  3.  It  is 
probable  that  further  research  will  enable  us  to  enlarge  this  num- 
ber. All  forms  of  true  meningitis  are  probably  of  microbic  ori- 
gin. 4.  Meningitis  is  primary  and  secondary.  The  last-named 
form  of  the  disease,  developed  in  the  course  of  infectious  diseases, 
is  often  the  result  of  the  mixed  infection,  and  due  to  a  different 
microbe  from  that  which  excited  the  primary  infection.  5.  Cer- 
tain microbes  can  locate  primarily  in  the  meninges,  which  do  not, 
however,  choose  that  location  habitually.  "We  have  reason  to  be- 
lieve this  of  the  typhoid  bacillus.  We  may  thus  admit  a  cerebral 
typhoid  without  tvphoid  fever.  6.  The  microbes  find  their  wav 
to  the  meninges  either  through  a  direct  route,  as  in  otitis,  or  by 
way  of  the  circulation.  The  last-named  course  is  far  the  more 
frequent. 

"  Huguenin,  from  an  extended  study  of  the  sources  of  infection 


134  DISEASES   OF  THE   NERVOUS  SYSTEM. 

in  meningitis,  reaches  the  conclusion  that  purulent  meningitis  is 
always  due  to  micro-organisms,  but  that  serous  meningitis  and 
fibrinous  meningitis  are  due  to  a  cause  which  is  not  yet  determined. 
He  recognizes  five  forms  of  bacilli  capable  of  exciting  meningitis, 
adding  to  those  mentioned  by  Adenot  the  bacillus  meningitis  of 
Neumann  and  Scheffer. 

"Bonome  claims  to  have  isolated  an  encapsulated  diplostrep- 
tococcus  from  a  meningeal  exudate  of  epidemic  cerebro-spinal 
meningitis,  which  he  regards  as  different  from  all  other  forms  yet 
found  in  this  disease.  He  does  not  consider  them  as  a  new  family 
of  bacteria,  but  as,  perhaps,  only  a  variety  of  the  lancet-like  diplo- 
coccus  of  Fraenkel.  Netter  reports  a  case  of  suppurative  men- 
ingitis following  a  pistol-shot  in  the  mouth,  in  w^hich  he  found 
the  pneumococcus  associated  with  the  staphylococcus  pyogenes 
aureus.  The  author  considers  the  case  as  confirmatory  of  experi- 
ments which  he  had  made  in  1886,  producing  meningitis  by  tre- 
phining and  introducing  a  culture  of  pneumococci  under  the  dura, 
the  pistol-ball  in  the  man's  case  laying  bare  the  under  surface  of 
the  brain,  just  as  the  trephine  had  a  superior  surface  in  the  animals 
experimented  upon."  * 

*  Landon  Carter  Gray,  Annual  of  the  Universal  Medical  Sciences,  Sajous, 
1891. 


DIFI*ERENTIAL   DIAGNOSIS. 


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LECTURE    YIII. 

PACHYMENINGITIS. 

Forms  of  Meningitis — Pachymeningitis — Pachymeningitis  Externa — Pachymeningitis 
Interna  or  Hsemorrhagiea — Etiology  :  Blows,  Injuries,  Oz»na,  Otorrhoea — Anatomi- 
cal Characters — Clinical  History — Hagmatoma  of  the  Dura  Mater — Inflammation  of 
the  Cerebral  Sinuses — Thrombosis — Metastatic  Ab&cesses  in  the  Lungs — Symptoms — 
Causes  of  Death — Treatment — Prognosis — Pathological  Anatopiy — Cranial  Surgery 
in  Pachymeningitis. 

GENTLEiiEN, — In  my  last  lecture,  while  speaking  to  you  upon 
the  subject  of  cerebro-spinal  meningitis,  I  discussed  its  connection 
with  different  diseases,  such  as  typhus  fever,  scarlatina,  malarial 
fever,  etc.,  with  which,  at  least  by  some  authors,  it  has  been  con- 
founded. I  compared  its  clinical  and  pathological  phenomena 
with  those  of  each  of  these  diseases,  affirming  my  belief  that  it 
was  not  in  any  manner  connected  with  them.  I  moreover  took 
the  position  that  it  is  not  primarily  a  nervous  affection,  but  an 
essential  fever,  somewhat  resembling  t^'phus  in  its  action,  and  that 
in  cerebro-spinal  meningitis  a  peculiar  materies  morhi  probably 
exists,  whose  action  upon  the  cerebro-spinal  nervous  system  causes 
the  inflammation  of  the  meninges. 

In  the  consideration  of  the  different  diseases  of  the  membranes 
covering  the  brain,  we  have  thus  far  reviewed  :  first,  acute  idio- 
pathic ;  secondly,  tuberculous ;  thirdly,  cerebro-spinal,  meningitis. 
In  each  of  these  diseases  there  is,  as  we  have  already  seen,  an  in- 
flammation of  the  pia  mater  as  well  as  of  the  arachnoid.  We 
now  come  to  the  description  of  the  fourth  form,  the  last  but  one 
that  we  will  study.  It  is  a  variety  of  rare  occurrence,  against 
which,  however,  you  must  be  constantly  on  your  guard,  never 
allowing  it  to  elude  your  vigilance,  as  it  is  apt  to  deceive  the  in- 
experienced physician.  This  affection  is  known  as  pachymenin- 
gitis, or  inflammation  of  the  dura  mater. 

If  you  have  carefully  followed  me  in  my  previous  lectures,  you 
will  recollect  that  in  the  other  varieties  of  meningitis  the  dura 

137 


138  DISEASES   OF   THE   NERVOUS   SYSTEM. 

is  not  involved.  In  the  present  malady,  however,  the  inflam- 
mation is  almost  exclusively  limited  to  that  membrane,  the  others 
remaining  healthy. 

The  dura  mater  is  composed  of  two  layers, — an  inner  one, 
having  an  epithelial  surface,  and  an  outer  one,  thicker  and  serving 
as  a  periosteum. 

Pachymeningitis  is  distinguished  as  external  when  the  outer 
layer  of  the  dura  is  inflamed,  and  internal  when  the  inner  dural 
membrane  is  involved.  The  latter  form  is  known  as  hsematoma 
of  the  dura  mater. 

EXTERNAL   PACHYMENINGITIS. 

This  affection  is  generally  secondary.  Fractures  of  the  cranial 
bones  produce  it  sometimes,  by  an  extravasation  of  blood  between 
the  bone  and  the  dura.  Erysipelas  has  been  known  to  be  a  factor 
in  its  production. 

It  should  be  distinctly  remembered  that  in  pachymeningitis  the 
dura  alone  is  affected. 

Gowers  very  appropriately  states  that,  "of  the  three  mem- 
branes that  enclose  the  brain,  only  two  are  pathologically  separa- 
ble, since  the  arachnoid  and  pia  mater  always  suffer  together.  The 
separate  inflammation  of  the  dura  mater,  'pachymeningitis/  is  much 
less  common  than  the  affection  of  the  pia-arachnoid,  which  is 
commonly  meant  when  '  meningitis'  is  spoken  of.  The  affection 
of  the  soft  membranes  has  been  of  late  termed  '  leptomeningitis,' 
in  more  precise  antithesis  to  pachymeningitis." 

Caries  of  the  petrous  and  ethmoid  bones  and  of  the  upper 
cervical  vertebrae  are  well-known  causes  of  pachymeningitis. 

"  From  my  experience,  which  is  not  entirely  exhausted  by  the 
preceding  cases,  I  cannot  hold  idiopathic  pachymeningitis,  inde- 
pendent of  external  injury  or  syphilis,  to  be  so  rare  a  disease  as 
authors  affirm.  I  believe  the  disease  is  frequently  mistaken,  and 
supposed  to  be  a  febris  larvata,  on  account  of  the  regular  inter- 
missions, or  more  frequently  a  cephalcea  rheumatica. 

"  At  first  sight  it  may  aj)pear  strange  that  this  inflammation  is 
distinguished  by  such  intense  painfulness.  It  must  be  remem- 
bered, however,  that  the  dura  mater  cerebri  consists  of  two  layers, 
of  which  the  outer  forms  the  periosteum  with  which  the  dura 
mater  proper  is  coherent.     The  great  painfulness  in  consequence 


PACHYMENINGITIS.  139 

of  inflammation  is  possessed  by  the  dura  mater  in  common  with 
the  periosteum  of  other  bones.  The  dura  mater  of  the  vertebral 
canal,  separated  from  the  periosteum,  is,  according  to  my  experi- 
ence, far  less  painful  in  inflammation  than  the  dura  mater  cerebri. 
Also  degenerations,  ossifications,  and  even  inflammation  of  the  falx 
cerebri  appeared,  in  a  few  cases  which  have  occurred  to  me,  not  to 
pm'sue  a  very  painful  course.  In  the  vertebral  canal  an  isolated 
inflammation  of  the  dura  mater  occurs  indeed  only  seldom,  and 
on  that  account  we  have  no  perfectly  pure  observations.  How- 
ever, I  have  not  observed  the  pains  occurring  here  in  such  sever- 
ity, although  perhaps  they  proceeded  from  other  parts.  If  the 
disease  takes  a  more  chronic  course,  through  which  the  dura  mater 
unites  almost  inseparably  with  the  skull,  then  the  severe  pains  do 
not  always  occur.  Thus  was  it  with  the  seventy-two-year-old 
man,  where  the  skull  could  not  be  separated  from  the  dura  mater, 
and  where,  nevertheless,  no  headache  had  been  present.* 

"  The  intermittence  is  also  peculiar ;  it  often  occurs  as  distinctly 
periodic  as  in  intermittent  fever,  but  mostly  manifests  itself  irregu- 
larly, so  that  rather  long  complete  intermissions  are  distinguished. 
Here,  again,  we  recognize  the  correspondence  of  the  dura  mater 
with  the  periosteum  of  other  parts.  In  periostitis  generally  the 
pain  comes  on  more  severely  during  the  night,  or  it  has  even 
longer  intermissions.  Other  authors  also  mention  the  intermit- 
tence of  the  symptoms  of  the  disease.  Especially  many  observa- 
tions of  the  kind  are  found  in  the  works  of  the  distino-uished 
Lallemand.     (Recherches  sur  I'Enc^phale.)  .  .  . 

"  But  in  very  acute  cases  these  intermissions  appear  to  be  absent, 
or  perhaps  they  were  not  observed  in  the  beginning  of  the  disease, 
before  medical  treatment  was  commenced."  "j" 

Pachymeningitis  is  however,  we  believe,  rarely  idiopathic,  being 
almost  always  dependent  upon  some  secondary  cause ;  hence,  when 
it  exists,  we  can  generally  suspect  the  natiure  of  its  etiology.     It 

*  "  Probably  the  strong  coherence  of  the  periosteum  to  the  bones,  and  the 
great  tension  in  consequence  of  inflammatory  swelling,  through  which  an  in- 
jurious and  painful  pressiire  on  the  nerves  arises,  contribute  much  to  the  pain- 
fulness.  At  least  the  periostitis  which  always  occurs  after  fractures  or  after 
amputations  is  not  very  painful,  in  case  the  torn  edges  of  the  periosteum  do 
not  sustain  any  tension  and  are  not  exposed  to  pressure." 

t  Schroeder  van  der  Kolk,  Pathology  and  Therapeutics  of  Mental  Diseases. 


140  DISEASES   OF   THE   NERVOUS  SYSTEM. 

differs  considerably  in  this  respect  from  acute  idiopathic  meningitis ; 
a  child,  for  instance,  is  often  seized  with  the  latter  affection  without 
our  being  in  the  sKghtest  degree  able  to  ascertain  the  exciting  cause, 
but  in  pachymeningitis  there  are  certain  generally-recognized  in- 
fluences leading  to  its  production.  The  most  ordinary  of  these 
are  severe  blows  upon  the  head,  and  external  violence,  fractures  or 
fissures  in  the  skull,  to  which  we  may  add  diseases  of  the  hones 
of  the  cranium,  such  as  caries  (syphilitic  or  otherwise),  resulting 
from  ozsena. 

Another  very  common  and  important  source  of  pachymenin- 
gitis, which  I  wish  you  always  to  recollect,  and  one  which  is  not 
sufficiently  appreciated  or  recognized,  is  otorrhoea,  with  caries  of 
the  temporal  bones.  Otorrhoea  is  a  frequent  sequel  to  scarlatina 
or  other  exanthema,  such  as  rubeola  or  variola.  In  these  diseases 
there  is  usually  an  affection  of  the  throat,  an  inflammation  of  the 
pharynx,  which  is  more  or  less  persistent,  situated  in  the  mucous 
membrane  of  the  fauces,  which  by  continuity  of  structure  may  be 
transmitted  along  the  mucous  membrane  of  the  Eustachian  tube 
and  finally  involve  the  middle  and  internal  ear.  This  rapidly 
destroys  the  ossicula  auris,  attacks  the  deeper  layers  of  bone,  and 
finally  extends  to  the  dura  mater.  Jaccoud  states  that  when  the 
disorder  follows  an  injury,  as  a  blow  upon  the  head,  the  starting- 
point  of  the  inflammation  is  in  the  membrane  lining  the  external 
surface  of  the  skull, — the  pericranium.  The  inflammatory  con- 
dition of  the  pericranium,  for  reasons  not  obvious,  causes  the 
inflammation  of  the  dura  mater :  as  there  is  no  very  evident  con- 
nection between  these  membranes,  we  cannot  very  easily  explain 
the  mode  of  transmission  of  the  inflammation ;  though,  after  all, 
it  might  be  communicated  or  propagated  through  the  osseous 
structure. 

Considering  what  I  have  said  in  regard  to  otorrhoea,  you  will 
readily  understand  the  necessity  and  importance  of  its  energetic 
treatment,  notwithstanding  the  representations  of  parents  that  its 
cure  is  attended  with  danger.  As  a  rule,  mothers  do  not  wish 
an  interference  with  any  discharge.  This  is  an  old-fashioned  but 
still  prevalent  prejudice.  Formerly  it  was  considered  very  inju- 
dicious on  the  part  of  a  physician  to  arrest  or  check  purulent  dis- 
charges. I  have  seen  little  children,  covered  with  eczema,  scratch, 
suffer,  and  pass  sleepless  nights,  simply  because  the  family  physi- 


PACHYMENINGITIS.  141 

clan  acquiesced  in  the  wishes  of  the  mother,  who,  according  to 
some  traditional  notion,  imagined  that  brain-disease  would  inevi- 
tably follow  the  disappearance  of  the  eruption.  These  ideas,  as 
I  have  said  already,  are  held  not  only  in  regard  to  otorrhoea,  but 
also  with  respect  to  cutaneous  eruptions,  and  have  some  authorita- 
tive weight  in  their  support.  Owing  to  such  opinions,  many  an 
otorrhoea  has  been  allowed  to  run  its  pernicious  course,  involving 
caries  of  the  neighboring  bone,  inflammation  of  the  dura,  and  the 
death  of  the  patient.  It  is  always  well  to  respect  the  feelings  of  a 
mother,  but  you  should  never  allow  yourselves  to  be  dictated  to  by 
any  one  governed  by  prejudice.  Rather  decline  the  responsibility 
of  the  case.  "  The  fact  that  the  inflammation,"  Hammond  says, 
"  sometimes  alternates  with  skin-eruptions  is  interesting,  and  has 
been  repeatedly  noted.  A  case  of  the  kind  was  not  long  since 
under  my  care.  It  was  that  of  a  gentleman  who  had  attacks  of 
acute  pain  in  the  head,  accompanied  with  all  the  phenomena  of 
paralysis  of  the  left  third  nerve.  There  was  eifusion  of  lymph 
upon  both  optic  disks,  the  result  probably  of  old  optic  neuritis. 
Curiously  enough,  these  attacks  alternated  with  an  eczematous 
aifection  involving  the  trunk  and  especially  the  breast.  On  the 
disappearance  of  the  skin-disease  under  remedial  measures,  his 
head-symptoms  immediately  recurred,  and,  when  they  were  re- 
lieved by  the  action  of  the  iodide  of  potassium,  he  was  again 
attacked  with  eczema." 

In  this  case  the  intracranial  affection  was  evidently  devoid  of 
great  or  proximate  danger.  Not  so  with  pachymeningitis.  Hence, 
as  a  possible  cause  of  so  grave  a  malady,  you  must  at  once  arrest 
an  otorrhoea ;  do  not  temporize  with  it  for  a  moment  when  occur- 
ring under  the  circumstances  above  named ;  abolish  it  as  speedily 
as  you  can,  for,  on  account  of  the  existing  systemic  conditions, 
the  inflammatory  action  which  creates  the  discharge  is  exceedingly 
prone  to  extend  by  continuity  to  the  dura.  Nor  am  I  willing 
to  relax  anything  of  stringency  or  rigor  in  the  above  rule  for 
otorrhoeas  of  long  standing,  especially  when  they  have  ensued 
upon  the  exanthemata,  or  upon  a  purulent  otitis  media  of  what- 
ever origin.  The  most  chronic  cases  may  all  at  once  develop 
acute  symptoms  of  cerebral  character  most  insidiously  and  quickly 
carry  off  your  patient. 

In  order  to  illustrate  to  you  the  suddenness  of  death  in  some 


142  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

such  cases,  I  will  relate  an  incident  to  you  which  came  under  my 
direct  observation.  Before  its  recital,  I  can  conceive  that  you 
may  perhaps  inquire  if  in  pachymeningitis  we  do  not  first  observe 
symptoms  of  irritation  followed  by  those  of  depression,  or  marked 
headache,  convulsions,  vomiting,  contraction  of  the  pupils,  etc., 
previous  to  the  advent  of  coma.  In  answer,  I  would  say  that  in 
some  cases  such  symptoms  may  be  j^resent,  but  in  others  absent ; 
and  the  first  symptomatic  indications  will  often  be  those  of  depres- 
sion, those  of  irritation  having  been  so  slight  as  to  have  been  en- 
tirely overlooked,  and  coma  will  follow.  But  I  must  relate  my 
case,  as  an '  illustration  from  actual  experience  is  always  much 
more  instructive  than  a  long  disquisition.  I  wish  particularly  to 
impress  upon  you  the  necessity  of  caution,  by  citing  to  you  not 
my  triumphs  but  my  mistakes-,  in  order  that  you  may  be  pre- 
vented from  falling  into  errors  similar  to  my  own. 

Some  years  ago  I  was  the  physician  of  a  most  respected  and 
interesting  family,  one  of  whose  members  was  a  young  lady  about 
eighteen.  She  was  a  charming  girl,  very  intelligent  and  highly 
accomplished,  and  had  had  during  childhood  an  attack  of  scarla- 
tina, followed  by  an  otorrhcea  so  obstinate  and  persistent  as  to 
defy  all  treatment.  Dr.  Spencer,  a  distinguished  specialist  in 
aural  surgery,  had  treated  her  without  success.  About  the  time 
of  the  sad  occurrence  I  am  relating,  the  young  lady  was  noticed 
to  be  failing  in  health,  which  was  all  the  history  I  could  glean. 
She  was  not  very  sick,  but  the  mother  had  become  uneasy  and 
sent  for  me.  I  also  learned  that  there  had  been  some  fever,  and, 
being  somewhat  in  a  hurry,  I  diagnosticated  on  the  spur  of  the 
moment  intermittent  fever,  which  was  then  quite  prevalent.  Upon 
questioning  the  mother  further,  I  learned  that  the  girl  had  had 
severe  headache  for  a  few  days  previously,  and  also  that  she 
imagined  her  daughter  was  at  times  somewhat  delirious.  This 
was  perfectly  compatible  with  my  diagnosis.  As  she  also  had 
a  sore  throat,  I  proceeded  to  examine  it  carefully.  Bringing 
her  near  the  gaslight,  I  noticed  that  the  light  greatly  hurt  her 
eyes,  in  consequence  of  photophobia,  but  paid  no  attention  to 
this  important  fact.  Still  believing  that  she  had  malarial  fever, 
and  her  tongue  being  coated,  I  prescribed  calomel  and  quinine, 
and  then  left,  promising  to  return  the  next  day.  The  mother, 
beino;  nervous  and  anxious  about  her  child,  followed  me  to  the 


PACHYMENINGITIS.  143 

door  and  asked  for  my  opinion.  I  immediately  proceeded  to  re- 
assure her,  firmly  believing  that  the  quinine  would  do  its  work, 
so  I  told  her  that  there  was  no  cause  for  alarm,  as  the  young  lady 
would  be  well  in  a  few  days.  About  eleven  o'clock  the  same 
night  I  received  a  message  from  a  neighboring  physician,  who 
desired  my  presence  at  the  house  of  my  patient,  stating  also  that 
she  was  dying.  I  thought  it  was  probably  some  hysterical  trouble, 
making  him  over-anxious,  but  still  went,  intending  to  reassure 
him.  I  had  scarcely  entered  the  room  before  I  recognized  that 
she  was  comatose,  and  the  same  minute  I  appreciated  my  sad  error 
of  diagnosis.  I  had  overlooked  the  importance  of  the  otorrhoea, 
although  aware  of  its  existence,  which  in  such  cases  points  to  a  con- 
tingent pachymeningitis,  in  the  forcible  language  of  Niemeyer, 
like  an  impending  "  sword  of  Damocles."  The  otorrhoea,  photo- 
phobia, headache,  constipation,  and  delirium  were  all  known  to 
me  at  my  first  visit,  yet  I  overlooked  the  danger  and  gave  an 
encouraging  prognosis  !  I  was  baffled  and  mortified,  as  the  lady 
died  that  same  night,  and  I  should  have  anticipated  the  unfortu- 
nate termination  of  her  illness.  It  was  a  lesson  which  is  still 
indelibly  impressed  upon  my  mind.  If  this  mistake  of  mine  can 
be  at  all  beneficial  to  you,  if  an  otorrhoea  with  cerebral  symptoms 
can  make  you  apprehensive,  and  sound  the  note  of  alarm,  when 
presented  for  your  consideration,  then  I  am  amply  repaid  in  having 
related  my  melancholy  experience.  You  will  have  remarked  how 
very  few  were  the  symptoms  of  irritation  in  this  case,  how  rapidly 
coma  supervened,  carrying  the  patient  off  before  alarming  symp- 
toms had  manifested  themselves.  You  see,  therefore,  that  pachy- 
meningitis is  an  affection  to  be  dreaded,  and  you  will  bear  in 
mind  the  possibility  of  an  extension  of  disease  from  the  ear  to 
the  dura  mater. 

INFLAM^klATION    AND   THEOMBOSIS    OF   THE    CEREBRAL   SINUSES. 

You  are  all  acquainted  with  the  peculiarities  of  the  dura  mater, 
its  sinuses,  and  their  peculiar  anatomical  relations.  IS'ow,  when 
an  inflammatory  condition  of  the  dura  exists,  there  will  be  de- 
veloped a  tendency  to  the  formation  of  thrombi  in  the  cerebral 
sinuses,  with  subsequent  inflammation  of  their  walls.  The  in- 
flammation of  the  dura  may  be  propagated  to  the  sinuses,  stasis 
of  blood  will  occur  within  them,  and  a  clot  or  thrombus  being 


144  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

formed  will  interrupt  the  circulation  and  clog  their  cavity.  This 
is  one  of  the  contingent  dangers  of  inflammation  of  the  dura 
mater,  and  according  to  the  location  of  tlie  primary  cause  will  a 
particular  sinus  become  involved.  In  ozsena  and  caries  of  the 
ethmoid  bone,  the  longitudinal  sinuses  will  be  implicated,  while  in 
caries  of  the  petrous  portion  of  the  temporal  bone  the  lateral  and 
petrosal  sinuses  will  be  inflamed. 

From  your  knowledge  of  thrombosis  and  embolism,  you  are 
aware  that  the  interference  with  the  circulation  in  the  cerebral 
sinuses  is  not  the  only  danger  to  be  apprehended,  as  there  may  be 
another  important  complication, — a  metastatic  abscess  in  the  lung. 
You  should  always  remember  that  thrombosis  may  result  in  em- 
bolism, as  sometimes  occurs,  for  instance,  after  inflammation  of 
the  uterine  sinuses,  and  also  in  phlebitis  resulting  from  fractures 
or  other  causes.  We  have  already  seen  how  the  embolus  becomes 
detached  and  is  taken  to  the  right  ventricle  and  thence  to  the 
lungs,  where,  if  large  enough,  it  will  plug  up  the  pulmonary 
artery,  or  one  of  its  important  branches,  producing  death  by 
apnoea.  But  if  the  clot  be  small  and  derived  from  a  suppurative 
focus,  a  metastatic  abscess  will  be  produced  in  the  lung.  This  is 
exactly  what  sometimes  happens  in  pachymeningitis.  Ideas  upon 
this  subject  were,  up  to  a  recent  date,  of  a  very  crude  character. 
You  will  now  be  able  fully  to  realize  the  danger  of  this  disorder, 
and  also  to  understand  its  mode  of  origin. 

Thrombosis  of  the  cerebral  sinuses,  with  resulting  metastatic 
abscesses,  may  be  suspected  when  rigors  occur  during  the  course 
of  pachymeningitis. 

Gerhardt  states  that  a  grave  suspicion  of  thrombosis  of  the 
transverse  sinus  exists  when  there  is  "  less  fulness  of  the  jugular 
vein  drawing  its  blood  from  the  obstructed  sinus." 

This  fact  would  be  corroborated  by  a  symptom  upon  which 
Griesinger  lays  stress,  which,  it  is  true,  he  found  in  only  one  case, 
— namely,  "a  circumscribed  painful  oedema  behind  the  ear;" 
although,  as  Niemeyer  observes,  "  in  caries  of  the  mastoid  process 
this  oedema  (which  Griesinger  calls  a  phlegmasia  alba  dolens  in 
miniature)  may  arise  from  other  causes  than  from  the  extension 
of  the  thrombus  though  the  emissaria  Santorini  which  pass  out 
in  the  sigmoid  fossa." 


PACHYMENINGITIS.  145 

ANATOMICAL   APPEAEANCES   OF   PACHYMENINGITIS. 

The  dura  mater  is  thickened,  and  may  be  found  attached  to  the 
cranial  bone,  with  accompanying  ossification  of  the  proliferated 
connective  tissues.  There  is  great  swelling,  increased  vascularity, 
and  oedema  of  the  dura. 

Pus  may  be  found  between  the  dura  and  the  bone  ;  occasionally 
between  the  two  layers  of  the  dura.  The  pia-arachnoid  may  be 
adherent  to  the  internal  layer  of  the  dura. 

Ecchymoses  of  diminutive  character  are  observed. 

The  dura  is  at  times  discolored  and  softened. 

When  pus  has  been  formed,  the  dura  may  be  detached  more 
or  less  extensively  from  the  bone. 

It  is  not  easy  to  ascertain  whether  the  inflammation  of  the 
sinuses  is  primary  or  secondary  to  the  thrombosis. 

The  thrombi  may  be  adherent  to  the  walls  of  the  sinus,  or 
broken  down  and  infiltrated  with  offensive  pus, 

"  Along  with  these  changes  we  generally  find  those  of  otitis 
interna  and  extensive  caries  of  the  petrous  bone, — viz.,  destruction 
of  the  drum,  absence  of  the  ossicula,  polypoid  proliferations  of 
the  mucous  membrane,  the  tympanum  full  of  pus,  which  also 
infiltrates  the  labyrinth,  cochlea,  and  mastoid  cells."    (Niemeyer.) 

"The  example  of  Macewen,  in  scraping  out  and  thoroughly 
disinfecting  the  middle  ear  when  this  has  become  hopelessly 
destroyed  by  the  primary  purulent  inflammation,  should  be  more 
generally  followed  in  operating  for  cerebral  abscess  traceable  to 
this  cause,  as  such  a  measure  is  well  calculated  to  protect  the 
patient  against  subsequent  infection.  The  foregoing  cases  furnish 
abundant  proof  of  the  utility,  as  a  life-saving  operation,  of  timely 
surgical  interference  in  all  cases  where  well-defined  cerebral  symp- 
toms point  to  the  extension  of  the  purulent  process  from  the  ear 
to  the  brain  or  its  meninges,  even  when  well-marked  focal  symp- 
toms are  absent,'^  as  an  exploratory  operation  under  strict  antisej)tic 
precautions  would  not  constitute  a  source  of  danger ;  and  if  pus 
is  found,  early  incision,  drainage,  and  disinfection  may  often  suc- 
ceed in  saving  a  life  that  under  any  other  form  of  treatment  would 
be  hopelessly  lost."  f 

*  Italics  my  own. 

X  Senn,  Surgery  of  the  Brain,  Ann.  Univ.  Med.  Sci.,  Sajous,  1888. 

10 


146  DISEASES   OF   THE   NERVOUS   SYSTEM. 


LESIONS   FHOM   EAR-DISEASE. 

G.  Newton  Pitt,  in  the  first  of  the  Goulstonian  lectures  for  1890 
upon  the  subject  of  cerebral  lesions,  gives  an  interesting  analysis 
of  fifly-seven  fatal  cases  of  ear-disease  affecting  the  contents  of 
the  cranial  cavitv.  Nearly  all  the  cases  occurred  in  patients  under 
thirty  years  of  age,  only  nine  being  over  thirty.  Four  were  babies 
less  than  three  years  old.  As  an  illustration  of  the  difficulties 
attending  a  diagnosis  in  ear-disease  as  associated  with  brain-symp- 
toms, he  mentions  the  fact  that  in  more  than  one-sixth  of  this  series 
the  patient  died  without  any  otorrhoea  having  been  noticed.*  In  all 
the  cases  in  which  pyaemia  occurred,  the  onset  was  preceded  by 
thrombosis  of  the  lateral  sinus.  Death  was  caused  in  all  but  two 
of  these  cases  by  intracranial  complications, — among  them  ab- 
scess, mastoid  suppuration,  meningitis,  and  sinus  thrombosis.  Of 
the  abscess  cases,  three  were  in  the  cerebellum,  one  in  the  pons, 
two  in  the  centrum  ovale,  and  the  remaining  twelve  in  the  temporo- 
sphenoidal  lobes.  In  only  two  of  the  abscess  cases  was  there  any 
fever  due  to  the  abscess.  The  temperature  was  rarely  high  with 
uncomplicated  cerebral  abscess  ;  2°  F.  above  the  normal  in  six 
cases.  In  eight  it  was  high ;  three  of  these  had  meningitis,  two 
thrombosis  of  the  lateral  sinus.  The  author  reaches  the  following 
conclusions  : 

"  First,  abscess  in  the  temporo-sphenoidal  lobe,  which  is  by  far 
the  most  common  situation,  is  often  associated  with  an  inflamed  or 
sloughing  dura  mater  over  the  anterior  surface  of  the  petrous  bone 
or  pus  beneath  it.  Other  complications  are  infrequent,  except 
meningitis,  generally  due  to  extension  or  rupture  of  the  abscess. 
The  abscesses  are  almost  always  very  close  to  the  roof  of  the  tym- 
panum. Imperfect  drainage  of  the  (middle)  ear  is  frequently,  if 
not  invariably,  the  origin  of  the  mischief.  ISIastoid  suppuration 
often  aifects  the  posterior  surface  of  the  petrous  bone,  but  it  may 
be  associated  with  disease  limited  to  the  middle  fossa  of  the  skull. 
Cerebral  abscess  only  occurs  when  the  otorrhoea  has  lasted  for 
months  or  years.  The  symptoms  usually  come  on  insidiously. 
Rigors,  pyrexia,  and  optic  neuritis  are  all  infrequent  in  uncom- 
plicated cases,  but  all  occur  occasionally.     A  headache  of  intense 

*  Italics  my  own. 


PACHYMENINGITIS.  147 

severity,  and  a  dull,  sluggish  mental  state,  are  the  two  most  char- 
acteristic symptoms.  Cerebellar  abscesses  are  less  common,  and 
will  probably  be  associated  with  disease  of  the  dura  mater  behind 
the  petrous  bone,  or  with  thrombosis  of  the  sinus. 

"  With  regard  to  thrombosis  of  the  lateral  sinus  occurrino;  as  a 
complication  of  ear-disease,  it  is  stated  to  have  occurred  twenty-two 
times.  In  some  of  the  cases  there  was  well-marked  phlebitis,  but 
not  in  all.  The  thrombus  was  suppurating  in  more  than  half. 
The  thrombosis  developed  in  some  of  the  cases  directly  from  in- 
flammation or  necrosis  of  the  petrous  bone,  the  dura  being  inflamed 
or  sloughed  over  it.  In  three  cases  there  was  a  collection  of  pus 
outside.  In  other  cases  infection  had  spread  from  disease  of  the 
mastoid  cells  or  of  the  posterior  wall  of  the  tympanum  by  means 
of  the  conveyance  which  emptied  into  the  sinus,  the  dura  mater  not 
having  been  infected.  The  thrombus  giving  rise  to  sinus  throm- 
bosis is  generally  of  some  standing,  but  not  always.  The  chief 
symptoms,  nearly  always  of  sudden  onset,  are  pyrexia,  rigors,  pain 
in  the  occipital  region  and  in  the  neck,  associated  with  a  septi- 
csemic  condition  ;  well-marked  optic  neuritis  may  be  present.  The 
appearance  of  acute  pulmonary  mischief  is  almost  conclusive  of 
thrombosis.  The  average  duration  is  about  three  weeks,  and  death 
is  generally  from  pyaemia."  * 

Unfortunately,  there  are  no  particular  or  pathognomonic  symp- 
toms of  this  affection.  You  should,  however,  be  constantly  on 
your  guard  as  to  the  existence  of  the  conditions  of  the  primary 
disturbance,  which,  with  the  history,  will  give  you  a  clue  to  the 
diagnosis  as  well  as  the  treatment.  If  the  patient  has  received  a 
violent  blow  upon  the  head,  if  he  has  otorrhoea  or  ozsena  of  long 
standing,  and  before  death  exhibits  marked  general  cerebral  symp- 
toms, you  may  safely  conclude  that  the  disease  is  probably  pachy- 
menmgitis.  The  symptoms  of  the  affection  may  be  obscure,  but 
tlie  etiology  remains  clear.  Hence  it  is  that  I  do  not  wish  to 
dwell  upon  unimportant  symptoms,  the  main  object  being  that  you 
should  be  fully  acquainted  with  the  causes  of  the  disease,  and  that 
being  forewarned  you  may  be  forearmed.  Never  be  in  a  hurry 
when  making  a  diagnosis,  and  always  attach  paramount  impor- 


*  Landon  Carter  Gray,  Lesions  from  Ear-Disease,  Annual  of  the  Universal 
Medical  Sciences.  Sajous,  1891. 


148  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tance  to  otorrhoea  and  ozsena.  These  you  should  treat  in  time  to 
prevent  subsequent  symptoms  of  pachymeningitis  that  might  arise, 
otherwise  coma  will  supervene  and  you  will  be  utterly  powerless 
to  effect  any  good.  To  recapitulate :  recollect  that  in  otorrhoea, 
ozsena,  and  injuries  to  the  skull  you  are  to  apprehend  pachymenin- 
gitis, and  that  thrombosis  of  the  cerebral  sinuses  may  be  one  of 
its  results.  The  patient  may  die  of  occlusion  of  the  sinuses,  of 
inflammation  of  the  dura  mater  itself,  or  of  embolic  abscess  of  the 
lung.  Horsley  read  a  paper  before  the  Neurological  Section  of  the 
Tenth  International  Congress  on  the  "  Surgery  of  the  Central  Ner- 
vous System."  He  advocates  "  trephining  in  traumatisms  of  the 
brain,  especially  when  there  is  severe  and  obstinate  headache,  in 
pachymeningitis,'^  and  in  all  cases  where  the  existence  of  a  tumor  is 
suspected."  He  believes  that  gummata  are  not  amenable  to  medi- 
cal treatment,  and  should  be  removed  by  operation,  but  certainly 
some  experience  antagonizes  this  view.  He  would  tie  the  common 
carotid  arter}^  in  cases  of  cerebral  hemorrhage,  if  called  early,  f 

The  prognosis,  of  course,  is  necessarily  very  unfavorable. 

About  the  treatment  there  is  very  little  to  be  said.  You  may 
treat  the  brain-symptoms  in  this  disease  as  in  other  forms  of 
meningitis.  "  If  there  is  reason  to  suspect  the  formation  of  pus 
between  the  bone  and  the  dura  mater,  this  may  be  let  out  by 
trephining."     (Gowers.) 

ESiTEPvNAL  PACHY]SIEXINGITIS,  HEMATOMA  OF  THE  DUEA  MATER, 
OR  MENINGEAL  BLOOD-TUMOR. 

The  collections  of  blood  frequently  found  on  the  inner  surface 
of  the  dura  mater  after  death  are  not  due  to  the  rupture  of  blood- 
vessels, but  are  the  results  of  chronic  inflammation,  as  was  clearly 
shown  by  Virchow. 

The  condition  is  usually  bilater^al.  Hsematoma  is  generally 
situated  near  the  sagittal  suture,  is  encapsulated,  and  is  nothing  but 
a  collection  of  hemorrhagic  exudations. 

A  membraneous  layer  of  tissue  exists  between  the  dura  mater 
and  the  arachnoid  ^vhich  may  be  adherent  to  both. 

Six  or  seven  layers  of  this  tissue,  forming  various  sacs  containing 

*  Italics  my  own. 

t  Packard,  Annual  of  tlie  Universal  Medical  Sciences,  Sajous,  1891. 


PACHYMENINGITIS.  149 

blood,  are  found.  The  blood  escapes  from  the  numerous  vessels 
formed  in  the  false  membrane  of  the  dura  mater,  and,  as  has  been 
hinted  before,  is  effused  between  the  layers  of  the  adventitious 
membrane. 

The  encapsulated  sacs  of  blood  may  be  "  four  or  five  inches 
long,  two  or  three  broad,  and  half  an  inch  thick."     (Niemeyer.) 

Hsematoma  of  the  dura  mater,  Gowers  asserts,  "had  previ- 
ously been  ascribed  to  primary  *  hemorrhage,  and  this  view,  ad- 
vocated by  Prescott  Hewitt  in  1845,  has  been  recently  revived 
by  Huguenin  :  the  question  is  still  undecided." 

The  contents  of  the  sac  may  be  filled  with  fluid  or  coagulated 
blood.  The  brain  is  more  apt  to  be  flattened  when  the  hsematoma 
is  on  one  side.  Aitken  describes  hsematoma  of  the  dura  mater  as 
"  sanguineous  flattened  masses,  composed  of  fine  layers  of  fibrin, 
spread  to  a  greater  or  less  extent  over  the  dura  mater,  accompanied 
by  small  extravasations,  which  are  converted  into  pigment.  By 
repetition  of  the  process  numerous  layers  come  to  be  deposited  one 
upon  the  other.  Numerous  and  large  blood-vessels  form  in  these 
layers,  and  from  these  vessels  renewals  of  the  hemorrhage  occur. 
The  disease  is  chronic,  and  terminates,  after  continued  cephalic 
suffering,  generally  suddenly,  with  symptoms  of  apoplexy."  The 
tissue  of  the  new  membrane  is  red  at  first,  afterwards  paler.  In 
some  places  the  membranes  adhere  and  form  loculated  spaces. 
Virchow  affirms  that  hemorrhage  occurs  from  inflammatory 
changes  in  the  new  membrane. 

The  disease  is  exceedingly  uncommon.  Gowers  remarks  that 
"its  rarity,  at  any  rate  outside  asylums,  may  be  judged  from  the 
fact  that,  during  the  forty  years  in  which  the  Pathological  Society 
has  received  the  curiosities  of  metropolitan  necroscopy,  not  a 
single  specimen  has  been  brought  before  the  society  from  any 
London  hospital." 

Niemeyer  says  that  "  the  disease  occurs  chiefly  in  old  age,  and 
remarkably  often  in  persons  with  mental  diseases  and  in  drunkards. 
It  appears  to  develop  sometimes  as  an  independent,  sometimes  as 
a  secondary  disease,  due  to  injuries  of  the  brow.  In  the  latter 
case  it  is  said  that  years  may  intervene  between  the  injury  and 
the  first  symptoms  of  hsematoma."     (Griesinger.) 

*  Italics  my  own. 


150  DISEASES   OF   THE   NERVOUS  SYSTEM. 

In  otlier  cases,  the  following  factors,  to  which  Griesinger  has 
called  attention,  enable  us,  with  more  or  less  assurance,  to  make  a 
diagnosis  of  hsematoma  of  the  dura  mater :  "  If  circumscribed  head- 
aches,  gradually  increasing  to  great  severity,  in  the  vicinity  of  the 
vertex  and  forehead,  be  the  first  and,  for  a  long  time,  the  only 
trouble  of  which  the  patients  complain,  and  if  between  the  ap- 
pearance of  these  pains  and  that  of  other  severe  brain-symptoms 
there  be  an  interval  not  so  short  as  in  acute  diseases  of  the  brain 
and  its  membranes,  but  shorter  than  in  most  chronic  diseases  of 
these  parts,  particularly  in  the  difFei'cnt  cerebral  tumors,  the  first 
suspicion  falls  on  inflammation  of  the  meninges,  particularly  of 
the  dura  mater,  since  inflammation  of  the  other  membranes  has  so 
great  a  tendency  to  sj)read  that  it  is  accompanied  by  diffuse,  not  by 
circumscribed,  headache.  We  are  the  more  justified  in  this,  as  the 
form  of  pachymeningitis  in  question  occurs  just  at  the  point  where 
the  patients  complain  of  pain.  If  the  patient  has  been  mentally 
diseased  before  the  commencement  of  the  headache,  or  given  to 
drinking  excessively,  or  if  he  had  an  injury  of  the  head,  particu- 
larly of  the  forehead,  some  time  previously,  there  is  still  more 
reason  for  supposing  the  case  one  of  pachymeningitis,  as  is  evident 
from  the  etiology.  But  we  also  know  that  this  form  of  menin- 
gitis usually  leads  to  a  large  eifusion  of  blood,  encroaching  on  the 
cerebral  cavity,  and  that  then  the  effusion  is  capsulated  on  one  or 
both  sides  of  the  sagittal  suture.  Hence,  if  the  headaches  be  sub- 
sequently accompanied  by  the  signs  of  compression  of  the  capil- 
laries of  the  cerebrum,  by  mental  disturbances,  loss  of  memory, 
diminished  power  of  thought,  increased  inclination  to  sleep,  which 
finally  increases  to  coma,  a  slowly  developing  and  usually  not  pure 
hemiplegia,  after  excluding  various  brain-diseases,  we  must  think 
of  hsematoma  of  the  dura  mater  as  being  in  the  first  rank  of  those 
that  may  possibly  be  present.  Since  in  hsematoma  of  the  dura 
mater  there  may  be  reabsorption  of  the  blood  and  consequent 
freedom  of  the  brain  from  the  pressure  on  it,  a  favorable  course 
of  the  disease  and  recovery  of  the  patient  speak  for  hsematoma  in 
doubtful  cases.  If  the  effusion  of  blood  does  not  take  place  grad- 
ually, as  in  the  course  of  the  disease  above  described,  but  occurs 
suddenly,  if  it  is  large  and  limited  to  one  side,  the  symptoms  are 
those  of  an  abundant  hemorrhage  in  one  side  of  the  cerebrum. 
On  superficial  examination  it  may  apjDcar  remarkable  that,  even  in 


PACHYISIENLXGITIS.  151 

large  hsematomata  of  one  side,  there  is  occasionally  no  hemiplegia, 
or  else  it  is  very  incomplete  ;  but  we  must  bear  in  mind  that  heema- 
toma  occurs  just  at  the  place  where  the  increased  pressure  on  one 
hemisphere  is  most  readily  transferred  to  the  other,  through  the 
free  communication  between  the  two  sides  in  the  interior  portion 
of  the  skull,  particularly  when  the  hemorrhage  comes  on  slowly." 
Among  the  symptoms  of  hsematoma,  Griesinger  also  lays  stress 
ou  the  almost  constant  contraction  of  the  pupil,  and  is  inclined  to 
regard  this  as  a  "  symptom  of  irritation  of  the  surface."  In  the 
previous  chapter  I  attempted  to  give  another  explanation  of  the 
contraction  of  the  pupil  (which  was  also  hypothetical)  in  diseases 
encroaching  on  the  space  above  the  tentorium.     (Niemeyer.) 

Aitken  considers  the  possible  antecedent  existence  of  syphilis  a 
factor  not  to  be  ignored  in  cases  of  htematoma  of  the  dura  mater. 
It  should  be  remembered  that  after  the  initiator}^  symptoms  of  irri- 
tation have  lasted  for  some  time  (and  after  the  usual  interval  follow- 
ing them)  symptoms  of  depression  may  ensue,  with  violent  and 
localized  cephalalgia  as  an  almost  pathognomonic  manifestation. 
The  psychical  functions  are  depressed,  the  memory  and  the  gen- 
eral intellect  impaired, — undoubtedly  results  of  the  pressure  upon 
the  convolutions  of  the  brain,  attended  by  consecutive  antemia 
or  softening,  occasioned  by  the  hsematoma.  Somnolence,  with  a 
gradually  increasing  tendency  to  coma,  becomes  more  and  more 
developed.  Occasional  attacks  of  transitory  unconsciousness  are 
produced  towards  the  termination  of  the  affection,  witli  the  de- 
velopment of  a  partial  hemiplegia. 

The  principles  of  treatment  in  hsematoma  of  the  dura  mater  are 
the  same  as  those  applicable  in  cases  of  cerebral  hemorrhage. 

EAN'NET'S  TABLE  OF  DIFFEKENTIAL  DIAGNOSIS  BETWEEN 
EXTEKNAL  PACHYMENINGITIS  AND  INTEKNAL  PACHY- 
MENINGITIS, OK  HEMATOMA  OF  THE  DUPvA  MATEK. 

External  Pachyjienestgitis.  Inteenal  Pachymenixgitis. 

Causes. 

Traumatism  of  the  calvaria.  Chronic  alcoholism  and  syphilis. 

Diseases  of  the  cranial  hones.  Acute  febrile  disorders  (fevers,  rheu- 
Caries  and  necrosis  of  the  cervical  ver-         matism,  and  puerperal  diseases). 

tebrss.  Chronic  diseases  of  the  heart,  tubercu- 
Suppurative  diseases  of  the  vertebral        losis,  and  the  paralysis  of  the  insane 
ligaments.  may  be  associated  with  it. 


152  DISEASES   OF   THE   NERVOUS   SYSTEM. 


DIFFERENTIAL   DIAGNOSIS    BETWEEN    EXTERNAL    PACHY- 
MENINGITIS     AND      INTERNAL      PACHYMENINGITIS.— 

\Continued.) 

External  Pachymeningitis.  Internal  Pachymeningitis. 

Causes. — [Continued.) 
It  rarely  follows   syphilitic  or  rheu-     Old  age. 

matic  conditions  of  the  cranium  or     Males   more  frequently  affected  than 
erysipelas  of  the  scalp.  females. 

Headache. 

Intense  and  circumscribed  headache  Periodical  headache  is  commonly  pro- 
usually  exists.  duced,  gradually  reaching  extreme 

intensity  whenever  the  acute   form 
exists. 

Convulsions. 
Slight  convulsions  are  common  at  the     Convulsions  are  rare. 
onset. 

Brain-Symptoms. 

Vertigo,  nausea,  and  vomiting  are  fre-  Weakness  of  the  memory,  apathy, 
quently  met  with  at  the  onset  of  the  somnolence,  and  delirium  are  the 
disease.  more  common  symptoms. 

Pupils. 
The  pupils  are  apt  to  become  unequal.     The  pupils  are  not  necessarily  affected, 
if  the   pressure   upon   the   brain  is        because   the    pressure   of   the   san- 
severe,  guineous  cyst  is  more  limited  than 

that  of  a  pus-exudation.     They  may 
be  contracted. 

Pulse. 
The  pulse  is  at  first   accelerated,  but     The  pulse  fails  to  exhibit  the  effects  of 
becomes   slow   and   irregular  when        general  cerebral  compression,  except 
cerebral  compression  is  produced.  in  severe  and  fatal  cases. 

Late  Symptoms. 
Coma  and  paralysis  follow  if  cerebral     Feebleness  of  the  limbs,  unsteady  gait, 
compression  or  abscess  is  produced.  and  changes  in  the  nutrition  indi- 

cate the  latent  progress  of  inflam- 
mation of  the  brain. 

Symptoms  in  Common. 
Both  forms  may  be  associated  with  headache,  convulsions,  coma,  paralj'sis 
syphilitic  history. 


LECTURE  IX. 

NEO-MEMBEANES  OF  THE  DUEA  MATEE. 

{Charcot.) 

Gentlemen, — In  connection  with  pachymeningitis,  a  study  of 
neo-membranes  of  the  dura  mater,  recently  developed  by  Charcot, 
is  of  great  importance,  especially  as  new  contributions  of  this 
author  upon  the  subject  have  just  been  issued  from  the  Parisian 
press  (Qiluvres  Completes  de  J.  M.  Charcot,  tome  ix.,  1890). 

Charcot  states  that  it  is  the  generally  accepted  opinion  in  France 
that  intra-arachnoidean  meningeal  hemorrhage  results  from  a  rup- 
ture of  the  vessels  of  the  visceral  layer  of  the  arachnoid,  and  that 
the  extravasated  blood  after  a  certain  time  becomes  encapsulated 
by  a  false  membrane  which  is  eventually  organized.  This  new 
membrane  is  formed  either  by  a  modification  of  the  superficial 
layers  of  the  arachnoid  or  by  plastic  exudation  from  the  parietal 
arachnoid. 

Three  hypotheses  may  be  invoked  to  explain  the  simultaneous 
presence  of  hemorrhage  and  of  membranous  neoplasms  in  the 
arachnoidean  cavity  :  (1)  a  hemorrhage  occurs  and  the  mem- 
branous products  ensue ;  (2)  the  new  membranes  are  formed  be- 
fore the  hemorrhage ;  (3)  the  hemorrhage  and  the  membranous 
products  date  from  the  same  period. 

Charcot  asserts  that  neo-membranes  are  developed  under  the 
influence  of  spontaneous  and  inflammatory  irritjition  of  the  dura 
mater.  On  the  other  hand,  far  from  believing  that  meningeal 
hemorrhage  antedates  the  formation  of  the  neo-membranes,  he 
is  satisfied  that  the  blood  proceeds  from  the  neo-membranes 
themselves. 

In  further  studying  the  subject,  our  author  reaches  the  follow- 
ing conclusions  :  (1)  Neo-membranes  may  form  upon  the  internal 
layer  of  the  dura  mater,  without  being  necessarily  preceded  or 
accompanied  by  extravasations  of  blood,  while  it  is  especially 

153 


154  DISEASES    OF    THE   XERYOUS   SYSTEM. 

notewoithy  that  the  hemorrhage  ncYer  precedes  the  formation  of 
the  membrane.  (2)  Meningeal  hemorrhage^  from  many  obserYa- 
tions,  must  be  regarded  most  frequently  as  an  epiphenomenon 
of  the  development  of  the  neo-membranes ;  or,  more  explicitly, 
the  hemorrhage  is  occasioned  by  the  accidental  rupture  of  vessels 
previously  formed  in  the  new  membranes. 

The  anatomical  and  pathological  history  of  neo-membranes  has 
been  satisfactorily  studied  only  of  late.  Heschl  \ras  one  of  the 
first  to  elucidate  the  subject.  He  claimed  that  they  were  de- 
veloped from  the  connective  tissue  of  the  parietal  layer  of  the 
arachnoid ;  in  this  tissue  vessels  form  early,  and  many  layers  of 
connective  tissue  become  thus  successively  superimposed  one  upon 
the  other. 

In  1856,  VirchoTT  described  these  neo-membranes  of  the  in- 
ternal layer  of  the  dura  mater  still  more  accurately.  The  dura 
mater,  a  membrane  apparently  little  liable  to  morbid  change, 
is  nevertheless  susceptible  of  inflammation.  Virchow  termed 
this  inflammation  pachymeningitis.  Pachymeningitis  may  be  in- 
ternal or  external,  according  as  the  inner  or  the  outer  layer  of  the 
dura  is  primarily  or  especially  involved.  Internal  pachymeningitis 
is  the  form  now  under  consideration ;  this  is  generally  chronic  and 
exudative.  At  an  early  stage  a  very  thin  layer  of  a  somewhat 
fibrinous  exudation  is  poured  out,  often  difficult  to  detect,  but 
usually  recognizable  by  scraping  the  surface.  By  degrees  this 
layer  increases  in  thickness  and  becomes  more  and  more  organized. 
Connective  tissue,  nuclei,  fiisiform  bodies  and  vessels  appear. 
Still  later  new  exudations  form  and  are  developed  in  turn  into 
similar  tissues.  Sometimes  from  five  to  twenty  superimposed 
layers  may  become  distinguishable ;  these  form  the  layers  of  more 
recent  origin  which  lie  in  the  closest  relationship  to  the  dura  mater, 
and  whose  organization  is  consequently  most  advanced.  Usually 
the  membrane  which  lies  in  immediate  contiguity-  with  the  dura 
mater  is  but  slightly  adherent  to  it.  The  dura  mater  on  a  level 
with  the  membranous  formation  is  but  rarely  altered,  with  the 
exception  of  occasional  injection. 

In  France,  M.  Brunet  (185^)  arrived  at  conclusions  similar 
to  those  which  Virchow  had  reached  three  years  previously. 
Brunet  pointed  out  that,  independently  of  other  conditions,  neo- 
membranes  were  foimd  occasionally,  post  mortem,  in  cases  of  gen- 


NEO-MEMBRANES   OF   THE   DURA   MATER.  ]  55 

eral  paralysis.  He  thinks  that  these  membranes  are  developed 
from  the  jjarietal  fold  of  the  arachnoid,  a  fold  whose  existence  he 
admits  after  discussion  of  the  contradictory  opinions  of  authors 
upon  the  subject.  Charcot  believes,  with  K5lliker,  that  this  layer 
has  no  real  existence,  at  least  in  the  majority  of  cases ;  it  is  only 
represented  by  a  layer  of  ejjithelium.  Brunet  affirms  that  neo- 
membranes  are  developed  from  an  organizable  blastema,  concealed 
by  this  questionable  parietal  fold ;  but,  as  the  elements  of  the  neo- 
membrane  are  very  probably  due  to  a  proliferation  of  the  cells  of 
the  dura  mater,  such  an  opinion  cannot  be  unhesitatingly  accepted. 

Calmeil  regards  the  membranes  of  the  arachnoidean  cavity  as 
inflammatory  products;  he  observed  them  in  cases  of  diffused 
peri-«ncephalitis. 

Virchow's  ideas  were  further  elaborated  in  Germany  by  Schu- 
berg,  who  insisted,  among  other  points,  upon  the  symptomato- 
logical  phenomena  associated  with  the  development  of  these  neo- 
membranes.  Still  later,  Hasse  gave  a  very  complete  description 
of  pachymeningitis,  in  great  part  based  upon  his  own  researches. 
The  pachymeningitic  products,  according  to  this  investigator,  are 
most  frequently  found  on  both  sides  of  the  falx  of  the  dura  mater ; 
the  membrane  formed  by  them  is  at  first  very  thin,  and  may  be- 
come in  the  end  firmly  adherent  to  the  dura  mater,  sometimes 
covered  by  new  epithelium.  Charcot,  in  a  case  studied  by  him- 
self, observed  epithelial  cells  in  varying  stages  of  fatty  degenera- 
tion upon  the  lamellae  of  the  neo-membrane.  Charcot  observes 
that,  if  Hasse's  observations  are  correct,  an  intimate  adhesion  will 
be  sometimes  established  between  the  neo-membrane  and  the  dura 
mater,  and,  if  at  the  same  time  a  new  epithelium  is  produced,  it 
may  become  very  difficult  to  affirm  that  the  fold  which  covers  the 
dura  mater  is  of  pathological  origin.  In  such  a  case  the  exist- 
ence of  a  parietal  fold  of  the  arachnoid  may  be  assumed,  although 
normally  this  fold  does  not  exist.  It  is  possible  that  Heschl, 
Calmeil,  Brunet,  and  other  authors  who  maintain  such  an  opinion 
may  have  observed  facts  of  this  character,  by  which  they  were  led 
to  admit  the  very  contestable  existence  of  this  lamina  of  the  arach- 
noid. 

Hasse  has  autoptically  encountered  pachymeningitis,  com- 
mencing in  pleuro-pneumonia,  pleuritis,  pericarditis,,  and  acute 
articular  rheumatism,  and  also,  rarely,  in  variola,  scarlatina,  and 


156  DISEASES   OF   THE   NERVOUS   SYSTEM. 

typhus.  He  states  that,  although  the  pachymeningitic  products 
often  undergo  a  progressive  evolution,  more  or  less  surely  result- 
ing fatally,  these  untoward  sequelae  of  inflammation  under  other 
circumstances  may  disappear  under  the  influence  of  the  reactive 
forces ;  the  membranes  will  then  become  thinned,  and  in  such 
cases,  as  stated  above,  may  become  very  intimately  adherent  to 
the  dura  mater  and  be  invested  anew  by  an  epithelial  layer. 

Charcot  finally  refers  to  Guido-Weber,  who  has  very  recently 
and  exhaustively  written  upon  this  subject,  like  the  authorities 
already  cited,  from  an  anatomico-pathological  stand-point. 

As  to  the  true  method  by  which  these  membranous  products 
are  developed  upon  the  internal  surface  of  the  dura  mater,  all 
authors  quoted  concur  in  teaching  that  the  neoplasms  once  de- 
veloped have  a  great  tendency  to  become  the  seat  of  fluxionary 
movements,  a  fact  explicable  as  much  by  the  phlegmasial  state  of 
neighboring  parts  as  by  the  rich  vascularization  of  the  neo-mem- 
branes  themselves.  Sometimes,  from  unknown  causes,  fluxionary 
movements  become  unusually  pronounced,  and  the  neo-membrane, 
becoming  itself  inflamed,  may  be  in  its  turn  the  point  of  origin 
of  exudations  and  inflammatory  products.  So  it  is  that  in  certain 
cases  a  more  or  less  abundant  serous  exudation  may  occur  between 
the  lamellse  of  a  neo-membrane,  even  resulting  in  true  serous 
cysts.  Virchow  called  this  form  of  the  disease  "  pachymeningeal 
external  hydrocephalus."  These  serous  exudations  have  been 
often  observed  by  Bayle  and  Calmeil.  Hasse  and  others  have 
studied  them.  In  subjects  of  advanced  age,  Hasse  has  somewhat 
frequently  encountered  serous  cysts  formed  in  the  neo-membranes 
compressing  the  brain  and  causing  a  certain  degree  of  atrophy  of 
the  cerebral  substance.  Calmeil,  moreover,  has  observed  serous 
exudations  not  only  between  the  folds  of  the  neo-membrane,  but 
also  between  it  and  the  visceral  arachnoid.  Fibrinous  exudations 
from  the  neo-membranes  also  have  been  observed  in  various 
localities. 

Sometimes  the  inflammatory  irritation  of  the  neo-membranes 
becomes  more  active,  and  pus  is  formed  :  Calmeil  and  Guido-Weber 
have  reported  cases  of  this  sort. 

By  the  arguments  submitted,  Charcot  hopes  that  a  sufficient 
foundation  has  been  laid  to  sustain  his  first  proposition, — viz., 
that  neo-membranes  of  the  dura  mater  are  very  often  developed 


NEO-MEMBEANES   OF   THE    DURA    MATER.  157 

as  a  result  of  inflammatory  processes,  without  previous  meningeal 
hemorrhage.  He  goes  on  to  show  that  in  a  great  number  of  cases, 
if  not  indeed  in  all,  intra-meningeal  hemorrhage  originates  from 
a  neo-membrane  of  great  vascularitj  and  relatively  very  volu- 
minous, and  that,  in  general,  the  vessels  of  these  neo-membranes 
are  very  thin  and  predisposed  to  easy  rupture  under  the  blood- 
pressure. 

Neo-membranes  once  developed  tend  to  increase  by  superim- 
position  of  new  layers,  from  which  peculiarity  accidents  more  or 
less  gmve  may  result.  Hemorrhage  is  not  an  integral  or  neces- 
sary phenomenon  of  their  evolution,  even  in  cases  which  are  other- 
wise characterized  by  intensity  and  gravity.  Often,  indeed  most 
frequently,  the  vascular  ruptures  take  place  at  a  definite  period,  and 
an  extravasation  of  blood  occurs  into  the  neo-membranes.  Many 
things  may  happen  under  these  circumstances.  Sometimes,  when 
the  extravasation  is  very  slight,  the  blood  forms  small  interlamel- 
lar  ecchvmotic  collections  ;  at  other  times,  when  effused  in  greater 
abundance,  it  separates  the  layers  of  the  neo-membrane  more 
or  less  conspicuously,  in  such  manner  as  to  produce  real  sanguine- 
ous cysts,  remarkable  occasionally  for  their  considerable  volume ; 
the  walls,  finally,  limiting  the  eifusion,  may  burst,  and  so  permit 
the  entrance  of  blood  into  the  arachnoidean  cavity.  These  various 
modes  of  hemorrhage  are,  in  point  of  fact,  phases  or  differing 
degrees  of  a  morbid  process  always  in  realit^^  the  same.  The  ec- 
chymotic  patches  result  from  the  rupture  of  very  small  vessels, 
while  the  sanguineous  cysts  and  intra-arachnoidean  hemorrhages, 
properly  speaking,  are  due  to  rupture  of  more  numerous  and 
voluminous  vessels.  In  all  cases  the  hemorrhage  will  be  found 
to  originate  in  the  vessels  of  the  neo-membrane. 

Such,  Charcot  believes,  is  the  usual  origin  of  meningeal  hem- 
orrhages. It  will  thus  be  seen  that  these  hemorrhages,  in  the 
greater  number  of  cases,  are  only  an  accident  of  pachymeningitis  ; 
a  complication  which  may  exist  without  a  definite  symptomatic 
expression,  as  when  the  extravasation  is  slight  and  disseminated, 
but  which,  on  the  contrary,  will  reveal  itself  by  a  more  or  less 
sudden  perturbation  and  by  grave  phenomena  when  there  is  a 
rapid  effusion  of  a  notable  quantity  of  blood. 

While  the  studies  of  Baillarger  were  important  in  subverting 
the  doctrine  which  located  the  seat  of  the  effusion  betsveen  th(! 


158  DISEASES    OF   THE   NERVOUS   SYSTEM. 

parietal  layer  of  the  arachnoid  and  the  dura  mater,  by  demon- 
strating that  its  real  seat  is  within  the  layer  itself  or  the  epithelial 
layer  which  represents  it,  the  well-known  hypothesis  put  forth  by 
this  eminent  observer  concerning  the  mode  of  development  of 
these  neo-membranes  can  no  longer,  in  Charcot's  opinion,  be 
entirely  sustained,  in  view  of  the  numerous  facts  in  formal  con- 
tradiction to  it. 

Before  the  publication  of  Baillarger's  memoir,  Calmeil  had 
already  been  led  to  believe  that  the  formation  of  false  membranes 
might  precede  intra-arachnoidean  hemorrhage ;  later,  in  1835,  he 
enunciated  more  peremptorily  a  similar  opinion.  Although  Bayle 
had  not  appreciated  the  fact  that  meningeal  hemorrhage  is  more 
often  only  epiphenomenal,  he  recognized  at  least  that  it  is  rare  to 
encounter  it  without  the  coexistence  of  a  false  membrane.  It  was 
Cruveilhier,  however,  Avho,  previously  to  the  most  recent  observa- 
tions, distinctly  formulated  the  true  theory  of  intra-arachnoidean 
hemorrhage.  Says  Charcot,  in  the  following  passage,  where  he 
speaks  of  the  formation  of  certain  tumors  of  the  internal  surface 
of  the  dura  mater  by  the  accumulation  of  caseous  puriform  matter 
originating  in  the  processes  involving  the  formation  of  the  pseudo- 
membrane,  "  I  recognized,  Cruveilhier  states,  that  these  tumors, 
ordinarily  oblong,  had  been  formed  on  the  internal  side  of  the 
parietal  arachnoid  and  had  resulted  from  a  pseudo-membranous* 
secretion  which  became  organized  and  formed  a  variety  of  cyst, 
in  whose  centre  was  found  a  material  of  variable  aspect  and  con- 
sistency. The  bloody  cysts  of  the  parietal  arachnoid  are  formed 
by  the  same  mechanism/'  Charcot  observes  that  these  few  words, 
hardly  more  than  rudimentary,  incontestably  express  the  true 
theory,  obscured,  however,  and  almost  lost  in  the  midst  of  facts 
which  it  did  not  explain,  and  on  this  account  passed  by  without 
recognition.  Still  later  Cruveilhier  elaborated  and,  we  may  say, 
definitely  formulated  this  theory. 

The  following  extract  is  of  great  importance.  "  IMy  position 
as  physician  for  many  years  at  the  Salpetriere,"  continues  Cruveil- 
hier, "permitted  me  to  demonstrate  that  arachnoidean  hemor- 
rhages had  as  a  point  of  departure  a  hemorrhagic  pseudo-mem- 
branous phlegmasia  of  the  parietal  arachnoid,  by  the  following 
mechanism  :  from  some  cause  difficult  to  determine,  a  pseudo- 
membrane  adherent  to  the  internal  face  of  the  dura  mater,  and, 


NEO-MEMBRANES    OF   THE    DURA    MATER.  159 

consequently,  to  the  parietal  fold  of  the  arachnoid,  is  formed ;  a 
false  membrane  is  never  found  upon  the  corresponding  arach- 
noidcau  visceral  layer.  This  false  membrane  is  sometimes  stained 
with  blood,  and  sometimes  contains  small  hemorrhagic  foci  in  the 
thickness  of  its  layers.  Sometimes  it  tears  and  pours  into  the 
arachnoidean  cavity  a  more  or  less  considerable  quantity  of  blood. 
It  is  this  false  membrane  which  is  the  source  of  the  hemorrhage, 
and  which  retains  and  encysts  the  extravasations  of  blood,  whose 
encystment  is  dependent  upon  the  development  of  the  false  mem- 
brane, which  organizes  without  contracting  adhesions  with  the 
visceral  layer  of  the  arachnoid,  while  the  blood  undergoes  all  the 
alterations  commonly  observed  in  closed  cavities." 

Thus  it  is  seen,  continues  Charcot,  according  to  Cruveilhier^s 
theory,  that  meningeal  hemorrhages,  and  sanguineous  cysts  of 
the  parietal  arachnoid  likewise,  originate  in  a  previously-formed 
false  membrane.  This  fundamental  conclusion  is  also  reached  by 
Heschl  and  Virchow  as  the  result  of  their  interesting  researches 
(Charcot  states,  in  a  foot-note,  that  Vii'chow  in  1856  compared 
the  intra-arachnoidean  sanguineous  and  membranous  exudates  to 
the  bloody  tumors  of  the  ear  (othsematomata),  and  designated 
them  as  hcematomata  of  the  dura  mater),  and  by  other  "German 
authors  already  referred  to  in  these  observations.  A  perfect  cor- 
respondence thus  exists  between  the  results  attained  by  the  French 
and  other  foreign  authors,  as  far  as  the  most  essential  points  are 
concerned,  and  it  is  especially  this  which  Charcot  so  ably  con- 
tributes to  establish.  As  a  matter  of  priority,  Charcot  states  that 
Heschl's  work  deserves  recognition :  histological  study  of  the 
subject  was  inaugurated  by  him  in  1855,  several  months  prior 
to  Cruveilhier's  publication. 

According  to  Charcot,  Calmeil  and  Brunet  finally  admitted  tliat 
the  production  of  meningeal  hemorrhage  is  dependent  in  the  ma- 
jority of  cases  upon  the  prior  existenc^e  of  neo-membranes,  their 
conclusions  being  similar  to  those  of  Cruveilhier,  Heschl,  and 
Virchow.  Their  conclusions  were  based  upon  a  great  number 
of  original  microscopical  and  clinical  investigations  supported  by 
pathological  histology. 

\Yhile  criticising  Brunet,  Charcot  maintains  his  work  to  have 
been  remarkably  original  in  these  two  latter  particulars,  although 
containing  some  opinions  which  admit  of  dispute ;  as,  for  instance, 


160  DISEASES   OF   THE   NEEVOTJS   SYSTEM. 

that  the  blood  in  intra-arachnoidean  hemorrhage  is  furnished  not 
by  the  vessels  of  the  neo-membrane,  but  by  those  of  the  parietal 
fold  of  the  arachnoid.  Charcot  states  that  he  cannot  admit  the 
validity  of  this  affirmation  ;  even  if  it  be  claimed  that  hemorrhage 
from  the  vessels  of  the  hypothetical  layer  of  the  arachnoid  pre- 
cedes that  from  the  dura  mater,  such  an  assumption  would  explain 
only  a  minority  of  the  facts  connected  with  the  process.  The 
vessels  of  the  neo-membrane  exhibit  qualities  much  more  in  ac- 
cordance with  the  supposition  which  assigns  to  them  the  source 
of  the  extravasations  of  blood. 

An  examination,  moreover,  of  the  seat  of  the  effusions  would 
lead  us  to  the  same  conclusion.  If  the  extravasations  be  not  very 
abundant,  they  will  be  generally  found  in  the  space  between  the 
folds  of  the  neo-membrane ;  if,  on  the  contrary,  they  are  very 
considerable,  they  will  be  more  frequently  found  in  the  cavity  of 
the  arachnoid,  or  they  will  be  separated  from  the  dura  mater  by  a 
more  or  less  thick  fold  of  the  neo-membrane.  Why  should  we 
suppose  in  this  case  that  the  blood  is  furnished  by  the  vessels  of 
the  inner  surface  of  the  dura  mater,  thus  involving  ourselves  in 
unnecessary  difficulties  ?  Were  this  hypothesis  correct,  we  must 
first  admit  that  a  rupture  of  the  vessels  of  the  dura  mater  had 
taken  place,  followed  by  a  laceration  of  the  internal  lamina  of 
this  membrane,  which,  on  the  contrary,  is  nevertheless  found  per- 
fectly intact  in  the  greater  number  of  autopsies.  Moreover,  if 
this  were  so,  Charcot  claims,  it  would  be  necessary  to  admit,  in 
cases  where  the  effusion  is  completely  encysted,  that  a  rupture 
of  the  most  external  layer  of  the  neo-membrane,  capable  of  per- 
mitting the  escape  of  a  relatively  considerable  quantity  of  blood, 
could  eventually  become  effaced  so  as  to  leave  no  traces  of  its 
occurrence.  Finally,  where  the  effusion  is  found  in  the  arachnoid 
cavity,  it  is  not  merely  a  thin  layer  of  the  neo-membrane,  but 
the  entire  neo-membrane  itself,  which  must  have  been  detached, 
distended,  and  finally  ruptured  at  some  point, — a  proposition 
difficult  to  entertain,  as  it  is  in  opposition  to  the  facts. 

Let  us  consider,  continues  Charcot,  from  another  point  of  view, 
the  structure  both  of  the  neo-membranes  and  of  the  vessels  which 
permeate  them,  and  we  will  recognize  conditions  eminently  favor- 
able to  the  production  of  hemorrhages  of  the  kind  we  are  studying. 
These  vessels  are  generally  very  numerous,  and  are  relatively  of 


NEO-MEMBRAIfES   OF   THE   DURA  MATER.  161 

large  size,  even  when  capillary ;  some  of  them  have  a  diameter  of 
two-  or  three-hundredths  of  a  millimetre,  yet  nevertheless  are  of 
the  rudimentary  structure  which  characterizes  the  normal  condition 
of  the  smaller  arterioles  or  venules ;  their  walls,  in  fact,  are  very 
thin  and  show  no  muscular  elements.  Whatever  may  be  the  de- 
gree of  organization  attained  by  the  tissue  of  the  neo-membrane, 
and  whatever  consequently  may  be  its  ultimate  density  and  resist- 
ance, such  a  structure,  we  may  say,  never  acquires  the  tenacity  of 
the  adjacent  normal  membranes.  Hence,  concludes  Charcot,  it  is 
readily  conceivable  that  the  vessels  as  well  as  the  intermediate 
tissue  may  easily  yield  and  tear  under  the  effects  of  blood-pressure ; 
all  the  more  easily  because,  in  certain  cases,  fatty  deposits  form, 
either  in  the  sides  of  the  vessels  or  in  the  thickness  of  the  elements 
which  constitute  the  neo-membrane,  in  such  a  way  as  to  weaken  the 
resistance  of  all  the  parts  concerned. 

When  we  admit  that  hemorrhages  consequent  upon  pachymenin- 
gitis originate  in  the  vascular  apparatus  of  the  neo-membranes,  it 
becomes  easy  to  understand  various  conditions  qualifying  the  effti- 
sion.  If  the  extravasation  of  blood  is  considerable,  or  if  the  mem- 
brane of  new  formation  at  a  somewhat  more  advanced  stage  of  its 
organization  is  composed,  for  example,  of  a  small  number  of  fragile 
and  thin  layers,  the  hemorrhagic  effusion  will  dilacerate  it,  easily 
breaking  through  it  in  many  places  and  finally  penetrating  into  the 
serous  cavity ;  this  constitutes  real  intra-arachnoidean  hemorrhage. 
If,  on  the  contrary,  the  neo-membrane  is  already  highly  organized, 
composed  of  thick  and  numerous  layers,  the  blood  will  force  itself 
between  these  layers  with  a  facility  inversely  proportional  to  the 
firmness  of  the  adhesion  of  these  layers  to  each  other.  In  a  foot- 
note Charcot  adds  that  the  neo-membranes  show  a  very  marked 
tendency  to  assume  a  capsular  form,  and  that  under  such  conditions 
we  will  almost  certainly  find  within  the  pseudo-capsule  either  blood, 
serous  fluid,  or  a  purulent  liquid.  (Calmeil.)  The  laminae  of  the 
membranes,  more  or  less  strongly  adherent  to  each  other,  do  not 
separate  equally  under  the  pressure  of  the  effused  blood,  and  inter- 
lamellar  centres  are  thus  produced,  which,  when  somewhat  con- 
siderable, constitute  veritable  blood-cysts.  Finally,  in  the  cases 
just  considered,  where  a  serous  cyst  is  developed  in  the  thickness 
of  the  neo-membrane,  it  is  plain  that  the  vessels  of  the  walls  of 
the  cyst  itself  may  rupture,  and  the  extravasated  blood  become 

11 


162  DISEASES   OF   THE   NERVOUS   SYSTEM. 

mixed,  in  variable  proportions,  with  the  encysted  serosity.  It  is 
quite  reasonable  to  assume  that  the  different  varieties  of  sero-san- 
guinolent  cysts  described  by  authors  are  formed  according  to  this 
mechanism. 

This  theory,  which  assigns  the  vascular  neo-membrane  of  in- 
flammatory origin  as  the  point  of  departure  of  intra-araehnoidean 
hemorrhage,  is  of  extended  pathological  significance,  and  serves  to 
explain  and  define  certain  non-traumatic  hemorrhages  which  occur 
in  serous  cavities  widely  remote  from  each  other  and  different  in 
function.  Charcot  here  quotes  Cruveilhier  once  more,  as  follows  : 
"  A  great  number  of  facts  have  demonstrated  to  me  that  all  the 
serous  membranes  are  subject  to  a  mode  of  inflammation  that 
may  be  termed  '  a  hemorrhagie  pseudo-membranous  phlegmasia.'  " 
Charcot  goes  on  to  say  that  a  considerable  number  of  cases  of 
pleurisy  and  pericarditis  styled  "hemorrhagic,"  evidently  of  this 
type,  can  be  cited,  where  the  blood  has  been  doubtless  furnished 
by  the  vascular  apparatus  of  neo-membranes.  Certain  vaginal 
hsematoceles  studied  by  Gosselin  may  be  considered  of  the  same 
character,  because  in  these  cases  the  blood  which  is  effused  in  the 
middle  of  the  serous  cavity  may  emanate  from  the  rupture  of 
numerous  vessels  with  attenuated  coats  which  are  distributed 
throughout  the  thickness  of  the  membrane  of  new  formation  de- 
veloped upon  the  vaginal  tunic.  It  is  known  likewise  that  some 
facts  pertaining  to  peri-uterine  heematoceles  have  been  presented 
by  Tardieu,  showing  these  forms  of  hsematocele  to  have  been  de- 
pendent upon  a  circumscribed  hemorrhagic  peritonitis.  A  circum- 
stance which  also  tends  to  prove  that  hemorrhagic  pachymeningitis 
and  various  hemorrhagic  neo-membranous  phlegmasise  are  allied 
morbid  conditions,  is  that  they  may  coexist  in  the  same  patient. 
Charcot  here  quotes  from  M.  G.  Weber  the  case  of  a  man  of 
fifty-one  years  of  age  where  examination  revealed  a  very  manifest 
pachymeningitis,  but  where,  besides,  in  the  right  pleura  there  was 
found  a  considerable  hemorrhagic  exudation,  in  the  midst  of  which 
lay  a  voluminous  blood-clot  of  recent  formation. 

To  the  considerations  thus  far  presented  in  favor  of  the  views 
sustained  by  Charcot  may  be  added  those  furnished  by  clinical 
experience  and  verified  by  special  sequences  and  concatenations 
of  symptoms  which  correspond  closely  with  definite  pathological 
movements.     From  a  symptomatological  stand-point,  two  prin- 


NEO-MEMBEAXES    OF    THE    DURA   MATER.  163 

cipal  forms  of  intra-arachnoidean  apoplexy  must  be  distinguished. 
Sometimes  the  disease  is  suddenly  developed  and  comports  itself 
like  an  accidental  affection  which  could  not  have  been  anticipated. 
Cases  of  this  nature,  relatively  few  in  number,  seem  to  be  inde- 
pendent of  pachymeningitis,  and  do  not  directly  engage  us  in  their 
study.  On  the  other  hand,  it  more  frequently  happens  that  the 
apoplectiform  attack  is  preceded  by  more  or  less  pronounced  and 
specially  marked  morbid  phenomena,  which  can  almost  always 
be  readily  recognized,  provided  the  period  of  observation  be  not 
restricted  to  the  last  days  of  life.  The  symptoms,  according  to 
Schuberg,  may  be  grouped  in  the  following  order  :  in  the  first 
period,  which  often  lasts  several  months,  there  exist,  besides  other 
symptoms,  a  gradual  weakening  of  the  memory  and  of  the  intel- 
lect, vertigo,  and  continued  or  remittent  cephalalgia,  which  may 
be  general  or  partial ;  at  a  later  period,  in  proportion  as  the  intel- 
lectual disturbance  becomes  aggravated,  somnolence  and  apathy 
appear ;  speech  sometimes  becomes  slow  and  embarrassed ;  the 
limbs,  especially  the  lower  ones,  become  weakened  and  the  per- 
formance of  their  movements  is  attended  with  a  sense  of  uncer- 
tainty ;  partial  and  incomplete  paralyses,  more  frequently  of  hemi- 
plegic  nature,  follow,  which  exhibit  the  particular  chara;^teristic 
that  they  are  often  augmented  and  diminished  with  great  celerity ; 
finally,  as  a  terminal  manifestation,  an  apoplectic  attack  occurs, 
whose  symptoms,  moreover,  have  been  perhaps  too  exclusively 
and  prominently  thrust  forward  in  classic  descriptions,  and  which 
generally  causes  death  in  a  short  time. 

Such,  Charcot  adds,  is  the  mode  of  evolution  of  the  morbid 
phenomena  in  the  cases  now  under  consideration.  If,  as  he  be- 
lieves, the  exudative  inflammation  of  the  dura  mater  necessarily 
precedes  the  hemorrhages,  the  relation  between  the  symptoms  and 
the  lesions  will  not  be  difficult  to  establish ;  the  weakening  of 
the  intellect,  the  cephalalgia,  the  prostration,  the  weakness  of  the 
extremities,  and,  in  fact,  all  the  symptoms  of  the  first  periods, 
being  due  to  the  pachymeningitis.  Recrudescences  of  the  sub- 
inflammatory  process  of  which  the  dura  mater  and  the  pseudo- 
membranes  are  the  seat,  followed  bv  a  cono;estion  of  neio-hborino- 
encephalic  parts,  and  perhaps  also  by  reflex  influences  affecting 
the  system  of  the  cerebral  circulation  more  or  less  extensively, 
are  finally  the  organic  causes  of  the  attacks  of  loss  of  conscious- 


164  DISEASES   OF   THE   NERVOUS   SYSTEM. 

ness  observed  in  a  certain  number  of  cases.  Paralysis  occurring 
at  this  period,  it  should  be  understood,  may  be  transient,  and  may 
cease  to  reappear  or  not,  as  it  is  dependent  upon  a  congestion  in 
its  turn  subject  to  augmentation  and  diminution,  either  partial 
or  total.  Pachymeningitis,  moreover,  may  remain  unrecognized 
when  very  mild,  and  also  when  appearing  in  the  midst  of  condi- 
tions in  which  the  cerebral  functions  are  already  disturbed :  it 
is  for  this  reason  that  pachymeningitis  is  so  frequently  ignored 
during  the  course  of  a  general  paralysis  with  which  it  coexists. 
The  apoplectic  symptoms  of  the  last  stage  depend  upon  a  more 
or  less  sudden  irruption  of  a  variable  quantity  of  blood  between 
the  layers  of  the  neo-membrane  or  into  the  arachnoidean  cavity 
itself.  It  is  unnecessary  to  enter  further  into  a  consideration  of 
this  subject  than  to  say  that  the  symptoms  will  be  found  to  vary 
in  accordance  with  the  abundance  of  the  extravasation. 

From  the  various  points  of  view  occupied  in  this  study,  Char- 
cot concludes  that  the  history  of  intra-arachnoidean  hemorrhage 
must  lead  to  certain  therapeutic  deductions  based  mostly  upon  the 
following  considerations.  (1)  Intra-arachnoidean  hemorrhage,  the 
most  common  of  meningeal  hemorrhages,  takes  place,  in  the  ma- 
jority of  cases,  in  individuals  suffering  during  a  longer  or  shorter 
period  from  pachymeningitis  :  it  then  proceeds  from  a  rupture  of 
the  vessels  contained  in  the  pachymeningeal  neo-membranes.  (2) 
Pachymeningitis  generally  declares  itself  by  a  collection  of  symp- 
toms which,  in  a  certain  number  of  cases  at  least,  is  capable  of 
attracting  attention  to  the  existence  of  the  affection.  (3)  The 
evolution  of  neo-membranes  developed  under  the  influence  of 
pachymeningitis  sometimes  terminates  by  a  retrograde  process,  at 
the  end  of  which  they  may  disappear.  It  follows  that,  if  signifi- 
cant indications  are  observed  adequate  to  excite  a  suspicion  of  a 
neo-membranous  inflammation  of  the  dura  mater,  the  further  de- 
velopment of  the  inflammatory  process  should  be  prevented  by  all 
the  methods  ordinarily  adopted  to  check  chronic  inflammation, 
and  such  a  course  should  be  all  the  more  insisted  upon  because 
this  affection,  as  has  been  said,  even  after  the  formation  of  organ- 
ized products,  may  retrograde  and  sometimes  completely  disap- 
pear. In  other  words,  by  instituting  the  radical  treatment  of 
pachymeningitis  we  may  forestall  and  prevent  the  occurrence  of 
intra-arachnoidean  meningeal  hemorrhage. 


LECTURE  X. 

GENERAL   MENINGEAL   HEMORRHAGE. 

Meningeal  hemorrhage  is  rare  except  as  a  result  of  trauma- 
tism. Effusions  of  blood  in  the  subarachnoid  space,  or  between 
the  dura  and  arachnoid,  are  due  for  the  most  part,  as  Niemeyer 
claims,  to  dilacerative  irruption  of  cerebral  hemorrhages,  burst- 
ing of  aneurisms  or  of  degenerated  arteries ;  in  many  cases  their 
origin  cannot  be  determined. 

According  to  Gowers,  in  meningeal  hemorrhage  blood  may  be 
extravasated  (1)  outside  of  the  dura,  separating  it  from  the  bone 
{extra-dural  hemorrhage) ;  (2)  beneath  the  dura,  into  what  was 
regarded  as  the  sac  of  the  arachnoid  when  it  was  thought  that  a 
parietal  layer  of  the  arachnoid  lined  the  dura  (sub-dural  hemor- 
rhage) ;  (3)  beneath  the  arachnoid,  between  it  and  the  pia  {sub- 
arachnoid hemorrhage).  The  blood  may  come  from  the  arteries, 
veins,  or  sinuses  of  the  dura,  or  from  the  vessels  of  the  pia. 

Gowers  enumerates  the  chief  causes  of  these  hemorrhages  as 
follows.  (1)  Injury  that  causes  fracture  of  the  skull  or  lacera- 
tion of  the  pia.  Extensive  hemorrhage  usually  proceeds  from  the 
meningeal  arteries  or  sinuses.  The  blood  may  be  outside  of  or 
beneath  the  dura.  (2)  Aneurisms  of  the  larger  arteries  of  the 
base  or  surface.  (3)  Rupture  of  an  intra-cerebral  hemorrhage. 
(4)  Meningeal  hemorrhage  occurs,  apart  from  visible  aneurisms, 
under  the  same  conditions  (age,  chronic  kidney  disease,  etc.) 
as  hemorrhage  elsewhere  in  the  brain.  It  is  also  met  with  in 
some  chronic  diseases  with  hemorrhagic  tendency,  as  purpura, 
leucocythsemia,  and  the  malarial  cachexia.  (5)  It  occurs  oc- 
casionally in  the  insane,  especially  in  the  subjects  of  general 
paralysis.  (6)  During  birth  it  may  result  from  the  compression 
of  the  skull,  especially  in  cases  in  which  the  head  is  born  last. 
(7)  Spontaneous  hemorrhage  from  a  meningeal  vein  has  been 
observed,  but  is  excessively  rare. 

165 


166  DISEASES    OF    THE   2sEEVOUS    SYSTEM. 

The  autoptical  appearances  in  meningeal  hemorrhage,  says  this 
author,  differ  according  to  its  seat  and  amount.  There  is  a  layer 
of  blood  upon  the  arachnoid  or  in  the  sub-arachnoid  space,  some- 
times in  both  localities.  The  blood  accumulates  especially  in  the 
sulci  and  depressions  of  the  cerebral  surfaces,  and  is  generally 
most  abundant  at  the  base  and  sometimes  limited  to  that  region. 
If  effused  in  considerable  quantity  over  the  convexity,  the  convo- 
lutions may  be  distinctly  flattened. 

The  resulting  symptoms  quite  often  do  not  become  manifest 
for  some  hours,  as  the  blood  escapes  more  or  less  slowly  from  the 
ruptured  artery.  This  is  very  significant  from  a  diagnostic  point 
of  view,  and  you  will  frequently  meet  with  cases  of  severe  head- 
injury  where  but  few  indications  of  trouble  occur  for  twenty-four 
hours,  when  the  development  of  cephalalgia  and  gradually  in- 
creasing coma,  accompanied  or  not  by  epileptiform  convulsions 
and  paralysis,  will  unerringly  point  to  the  nature  of  the  mischief. 
Such  hemorrhages  are  necessarily  diffuse,  and  the  resulting  symp- 
toms are  not  regional.  All  authors  agree  in  the  statement  that 
the  apoplectic  phenomena  are  most  highly  pronounced,  and  that 
this  form  is  quite  fatal,  Hemij)legia  is  usually  absent,  as  the 
hemorrhage  is  not  restricted  by  definite  anatomical  limitations, 
so  that  when  paralysis  occurs  we  necessarily  expect  it  to  be  general. 
In  all  diseases  affecting  the  convexity  of  the  cerebral  convolu- 
tions, epileptiform  con^nilsions  are  common.  Such  con\Tilsions, 
observed  duriag  profound  coma  without  hemiplegia,  are  pathog- 
nomonic of  meningeal  hemorrhage. 

In  some  cases,  says  Niemeyer,  the  coma  is  preceded  by  severe 
headache  and  vomiting,  and  in  others  by  general  convulsions.  He 
also  asserts  that,  "  since  these  symptoms,  particularly  the  latter, 
occur  only  exceptionally  in  cerebral  hemorrhage,  and  are  often 
seen  in  extensive  disease  at  the  convexity  of  the  hemisphere,  they, 
in  connection  with  the  absence  of  all  signs  of  hemiplegia,  enable 
us  to  decide  with  greater  certainty  that  the  case  is  not  one  of 
cerebral  but  of  meningeal  hemorrhage." 

The  symptoms  of  meningeal  hemorrhage  vary  greatly  according 
to  its  origin.  If  the  hemorrhage  is  due  to  a  rupture  of  a  large 
aneurism  at  the  base  of  the  skull,  there  will  be  intense  coma ;  if  to 
that  of  smaller  vessels,  the  effusion  of  blood,  Gowers  asserts,  will  be 
preceded  by  such  jDrodromata  as  giddiness,  headache,  and  vomiting. 


GENERAL    MENINGEAL    HEMOEEHAGE.  167 

The  same  author  calls  particular  attention  to  the  fact  that 
when  the  hemorrhage  is  of  traumatic  origin  the  effect  of  the  in- 
jury obscures  the  initial  symptoms,  because  "  in  these  and  similar 
cases,  in  which  the  escape  of  blood  is  gradual,  the  patient  may 
recover  consciousness  and  continue  his  occupation  for  some  hours, 
or  even  for  a  day  or  two,  complaining  only  of  headache,  and  then 
gradually  become  somnolent  and  pass  into  a  state  of  coma." 

In  menino;eal  hemorrhao-e,  Gowers  considers  the  convulsions 
the  most  prominent  symptom :  they  may  be  general,  unilateral, 
or  local.  Rigidity  of  a  limb,  he  states,  is  rarer  than  in  menin- 
gitis ;  delirium  or  mental  apathy  may  exist ;  the  pupils  may  be 
contracted,  dilated,  or  unequal.  The  variation  of  the  symptoms 
in  different  cases  is  very  great. 

Hammond  quotes  Prus  as  "  attempting  to  draw  a  symptomato- 
logical  distinction  between  sub-arachnoidean  and  intra-arachnoid- 
ean  hemorrhage.  .  .  .  But  most  authors  doubt  if  the  discrimina- 
tion can  in  reality  be  made  during  life.  Valleix  declares  that  the 
difference  is  of  greater  anatomical  than  symptomatological  impor- 
tance, and  Durand-Fardel  admits  that  it  is  difficult  to  present  a 
characteristic  view  of  the  course  and  phenomena  of  sub-arachnoid- 
ean hemorrhage." 

Menino;eal  hemorrhao-e  is  much  more  common  in  adult  life  than 
in  young  people.  Besides  traumatism  and  disease  of  the  vessels 
of  the  brain,  extreme  heat,  venereal  excesses,  excessive  mental 
exertion,  alcoholism,  and  obstructions  to  the  venous  outflow  from 
the  head,  etc.,  have  been  enumerated  as  exciting  causes.  One  of 
the  most  effective  predisposing  causes  of  meningeal  hemorrhage 
is  the  peri-arteritis  which  leads  to  the  development  of  miliary 
aneurisms,  so  graphically  described  by  Charcot  and  Bouchard. 
Haemophilia  and  gout  are  also  mentioned  as  causes.  The  disease 
is  most  frequent  in  the  two  extremes  of  life,  especially  in  new- 
born children  as  a  result  of  instrumental  labor. 

The  prognosis  in  nearly  all  cases  is  very  grave :  recoveries  are 
of  the  rarest  occurrence. 

I  must  not  forget  to  remind  you  of  Erichsen's  form  of  pro- 
gressive extra-dural  hemorrhage,  a  variety  which  is  often  mis- 
construed or  even  escapes  detection.  By  a  blow  from  a  blunt 
instrument,  as  a  sand-bag,  or  by  a  fall  upon  the  head,  the  dura 
may  be  detached  from  the  inner  surface  of  the  cranial  vault,  and 


168  DISEASES   OF   THE   NERVOUS   SYSTEM. 

hemorrhage  may  occur  which  does  not  necessarily  proceed  from 
the  rupture  of  the  meningeal  artery  or  its  main  branches.  The 
bleeding  has  its  source  in  the  laceration  of  the  nutritive  vessels 
of  small  size  which  pass  from  the  dura  to  the  bone.  As  blood  is 
poured  out,  the  dura  is  still  further  detached  and  the  collection 
of  blood  increases  in  size.  Here  the  symptoms  of  compression 
gradually  supervene,  and  after  a  period  of  many  hours  the  patient 
becomes  soporose  and  comatose.  Recollect  that  all  this  commonly 
occurs  without  fracture  or  even  external  contusion. 

The  treatment  is  similar  to  that  of  cerebral  hemorrhage,  which 
will  be  particularly  considered  in  the  second  volume  of  this  work. 
I  fully  agree  with  Hammond  that,  "in  those  cases  where  the 
symptoms  show  that  the  clot  is  confined  to  a  small  area,  tre- 
phining and  the  subsequent  removal  of  the  clot  may  be  success- 
fully accomplished." 


LECTURE  XL 

CKRONIC   CEREBRAL  MEKINGITIS. 

Hammond's  Classification — Brown-Seqnard's  Views,  etc. 

Gentlemen, — After  careful  thought,  I  have  concluded  to  adopt 
Hammond's  classification,  and  to  speak  of  this  subject  under  two 
captions, — viz.,  Chronie  Vertical  3Ieningitis  and  Chronic  Basilar 
Meningitis. 

For  much  of  the  spirit  of  this  lecture,  and  for  many  quo- 
tations contained  in  it,  I  am  indebted  to  a  "  Treatise  on  the  Dis- 
eases of  the  Nervous  System,"  by  Dr.  Hammond,  ninth  edition, 
1891. 

The  author  just  named,  referring  to  the  division  of  the  subject 
into  Chronic  Vertical  Meningitis  and  Chronic  Basilar  Meningitis, 
states  that  "the  terms,  being  applied  respectively  to  chronic  in- 
flammation of  the  membranes  of  the  superior  surface  or  vertex 
of  the  brain,  and  chronic  inflammation  of  the  membranes  of  the 
inferior  surface  or  base  of  the  brain,"  constitute,  according  to  hLs 
ideas,  the  proper  study  and  conception  of  the  comprehensive 
subject  of  chronic  cerebral  meningitis. 

CHRONIC   VERTICAL   MENINGITIS. 

An  acute  attack  of  meningitis  may  have  preceded  the  chronic 
form. 

ETIOLOGY. 

The  causes  of  chronic  cerebral  vertical  meningitis  are  but  too 
frequently  obscure.  Blows  upon  the  head,  diseases  of  the  bones, 
syphilis,  rheumatism,  exposure  to  extreme  heat,  emotional  and 
mental  influences,  are  all  powerful  factors  in  its  production. 
While  alcoholism  is  perhaps  the  most  general  and  influential  cause 
of  this  disease,  syphilis  is  perhaps  its  next  most  common  one,  but 
I  agree  with  Hammond  that  the  latter  malady  "  acts  preferably 

169 


170  DISEASES    OF    THE    NERVOUS    SYSTEM. 

upon  the   basilar  portion  of  the   membrane."      Gout  in   some 
instances  has  been  known  to  produce  it. 

ANATOMICAL   APPEARANCES. 

The  membranes  are  greatly  injected  and  sometimes  adherent  to 
each  other ;  there  is  increased  proliferation  of  connective  tissue ; 
the  meningeal  coats  are  thickened  and  less  transparent  than  normal. 

Fibrinous  exudations  are  frequently  encountered  both  on  the 
convexity  of  the  membranes  and  on  the  brain  itself. 

The  sub-arachnoidean  fluid  is  increased  in  quantity  and  may 
be  discolored  by  effusion,  and  pus  may  be  found  in  the  arachnoid 
cavity  and  in  the  meshes  of  the  pia.  Gelatiniform  exudations 
and  false  membranes  are  not  uncommon.  Cysts  containing  blood 
and  serum  are  also  encountered.  The  ventricles  at  times  are  found 
distended  and  their  ependyma  inflamed.  The  cortex  cerebri  may 
be  inflamed,  softened,  or  adherent  to  the  pia-arachnoid. 

SYMPTOMS. 

It  is  a  notable  fact  that  the  symptoms  of  chronic  vertical 
meningitis  at  times  greatly  resemble  those  of  the  disease  known 
as  "  progressive  general  paresis  of  the  insane,"  a  malady  to  be 
described  in  a  subsequent  lecture. 

Headache,  a  prominent  symptom  common  to  all  forms  of  me- 
ningeal inflammation,  is  almost  always  present.  The  pain  is  usu- 
ally diffused,  more  or  less  persident,  though  occasionally  remitting. 
It  is  commonly  felt  in  the  forehead  and  vertex,  and  is  aggravated 
by  movements,  especially  by  lowering  the  head,  and  by  intellectual 
effort.  Its  principal  characteristic  is  persistency.  Of  course  its 
intensity  is  not  so  great  as  in  the  more  acute  forms  of  meningitis. 

Lethargy  and  stupor,  weakness  of  the  limbs,  vertigo,  and 
tremor  constitute  a  well-known  symptom-group.  The  sphinc- 
ters are  more  or  less  affected.  Articulation  may  or  may  not  be 
impaired.  Spasms  of  special  groups  of  muscles  frequently  occur. 
The  mental  faculties  are  often  dulled.  Convulsions  sometimes 
occur.  The  cranial  nerves  are  not  so  frequently  involved  as  in 
other  forms  of  meningitis,  especially  the  basilar  form. 

Disturbances  of  sensation,  notably  neuralgic  pains  in  various 
parts  of  the  body,  are  not  uncommon. 


CHRONIC   CEREBRAL   MENINGITIS.  171 

The  weakness  of  the  limbs  appears  to  be  a  form  of  paresis 
rather  than  of  paralysis  proper,  although  absolute  hemiplegia  has 
in  some  cases  been  noted.  Optic  neuritis  is  rare.  Hammond, 
quoting  Dr.  Allbutt,  observes,  with  respect  to  the  optic  nerves 
in  drunkards  affected  with  meningitis  of  the  convex  surface  of 
the  brain,  that  they  are  "  often  degenerated,  and  the  vessels  in- 
jected, but  these  effects  do  not  seem  to  be  due  to  any  meningitic 
process." 

Should  the  cortical  substance  become  seriously  involved, — which 
does  not  often  happen, — the  mental  symptoms  will  become  more 
prominent  and  their  deterioration  but  too  evident. 

The  general  health  fails  in  some  cases,  but  in  many  instances  is 
little  affected. 

The  constipation  and  vomiting  occur  which  are  associated  with 
nearly  all  forms  of  meningitis.  In  some  cases  loss  of  sight  is 
produced  by  pressure  on  the  optic  nerves. 

If  the  case  grow  worse,  all  the  symptoms  will  converge  towards 
coma  and  death. 

The  duration  of  the  disease  varies  from  several  months  to 
several  years. 

An  interesting  though  infrequent  occurrence  should  be  men- 
tioned here.  An  intermittence  of  the  symptoms  often  exists,  and 
is  accompanied  by  what  Dr.  Fox  has  particularly  noted  (a  fact 
Dr.  Hammond  has  also  commented  upon  in  his  excellent  article 
on  chronic  cerebral  meningitis), — namely,  "the  lightness  of  the 
phenomena  when  compared  with  the  severity  and  extent  of  the 
lesions." 

These  remissions  in  the  symptomatic  manifestations  are  obscure 
and  very  difficult  to  explain. 

A  case  has  come  under  my  observation  illustrative  of  these 
statements.  It  was  one  of  a  physician,  presenting  many  symp- 
toms of  chronic  meningitis,  with  frequent  severe  exacerbations, 
accompanied  by  complete  forms  of  paralysis,  whose  frequent  re- 
missions were  at  times  so  marked  that  he  was  able  to  attend  to  his 
practice  when  the  exacerbations  of  his  affection  had  disappeared. 

Another  case,  probably  of  syphilitic  origin,  for  nearly  a  year 
presented  no  symptoms,  except  a  persistent,  intense,  diffused 
headache,  with  some  slight  impairment  of  sight ;  yet  I  feel  sure 
that  extensive  and  complicated  lesions  existed. 


172  DISEASES    OF   THE    NERVOUS    SYSTEM. 

I  beg  leave  to  quote  the  following  important  views  of  Brown- 
Sequard  in  this  connection  : 

"  If  we  compare  the  symptoms  produced  by  an  irritation,  such, 
for  instance,  as  that  of  one  of  the  lungs',  or  of  the  part  of  the 
base  of  the  brain  where  the  trigeminal  nerve  is  inserted  on  the 
pons  Varolii,  or  of  the  cerebral  meninges,  with  the  symptoms 
caused  by  an  irritation  of  any  part  of  the  brain,  we  find  that  in 
either  of  the  groups  of  cases  we  compare  there  may  be  paralysis 
produced  in  the  corresponding  or  on  the  opposite  side  of  the  body, 
and,  besides  that,  almost  any  of  the  symptoms  of  disease  of  the 
brain.  On  the  other  hand,  we  find  also,  and  in  many  cases,  that 
no  symptom  of  brain-disease  will  appear,  notwithstanding  an  or- 
ganic disease  in  the  cerebral  lobes,  in  the  base  of  the  brain,  in  the 
cerebral  meninges,  or  in  the  lungs. 

"  Led  by  facts  like  the  above,  and  by  many  others,  I  have 
necessarily  come  to  the  conclusion  that  there  are  nervous  elements 
in  the  various  parts  of  the  cerebral  lobes,  in  the  corpora  striata 
and  optic  thalami,  in  the  crura  cerebri  and  other  parts  of  the  base 
of  the  encephalon,  which,  like  the  nervous  elements  of  the  cere- 
bral meninges,  of  the  various  viscera,  the  skin,  the  mucous  mem- 
branes, the  trunks  of  nerves,  etc.,  have,  when  irritated,  the  power 
of  producing  on  some  part  of  the  nervous  centres — either  at  a 
short  or  at  a  very  great  distance  from  the  seat  of  the  irritation — 
changes  in  the  normal  state  of  activity  of  that  part. 

"  These  changes  may  consist  (a)  in  cessation  of  activity ;  .  .  . 
(b)  in  the  manifestation  in  a  morbid  form  of  the  activity  of  certain 
parts  of  the  ners^ous  centres.  .  .  . 

"  From  all  of  the  above  stateipents  and  from  the  study  of  every 
symptom  of  brain-disease,  I  have  drawn  the  conclusion  that  all 
the  parts  of  the  brain  resemble  the  peripheric  parts  of  the  nervous 
system,  in  being  able,  under  irritation,  to  act  on  any  other  of  its 
parts,  modifying  their  activity,  so  as  to  destroy  or  diminish  or  to 
increase  and  to  morbidly  alter  it."  * 

In  another  place  the  same  author  observes,  "  There  is  no  rela- 
tion whatever  betiveen  the  extent  of  a  lesion  in  the  brain  and  the 
production  of  symptoms.  .  .  .  This  can  be  expressed  in  other  and 


*  Brown-Sequard,  On  the   Mechanism  of  Production  of   Symptoms  of 
Diseases  of  the  Brain. 


CHRONIC   CEREBRAL   MENINGITIS.  173 

perhaps  more  forcible  words :  there  is  no  relation  whatever  be- 
tween the  extent  of  a  lesion  in  the  brain  and  the  symptoms  that 
may  be  caused  by  it.  If  the  symptoms  were  due,  as  is  admitted, 
to  the  loss  of  function  of  the  part  altered  or  destroyed  in  the 
brain,  or  to  immediate  effects  of  the  irritation  of  such  a  part, 
there  would  be  a  constant  relation  between  them  and  the  dis- 
ease, so  that  the  intensity  and  extent  of  the  symptoms  would 
be  in  proportion  with  the  intensity  and  the  extent  of  the  alter- 
ation. .  .  . 

"  The  mechanism  of  production  of  symptoms  of  brain-disease, 
as  I  have  already  said,  and  as  I  will,  I  hope,  succeed  in  showing  in 
a  special  paper,  is  identically  the  same,  whether  the  cause  is  in  the 
bowels,  or  in  any  thoracic  or  abdominal  viscus,  or  in  the  meninges 
of  the  brain,  or  in  any  part  of  the  brain  itself.  The  symptoms 
are  not  the  immediate  or  direct  effects  of  either  the  cessation  of 
function  or  a  morbid  action  of  the  part  diseased.  Wherever  is 
the  lesion  which  is  the  prime  mover  in  the  causation  of  symptoms, 
it  entirely  or  at  least  partially  produces  them  mediately  or  second- 
arily, or  indirectly,  and  through  the  agency  of  an  irritation  start- 
ing from  the  seat  of  the  lesion  and  acting  on  other  parts  which 
in  a  direct  way  give  rise  to  the  morbid  manifestations.  .  .  . 

"  A  lesion  of  the  brain  can  produce  a  cessation  of  symptoms 
of  brain-disease.  There  are  facts  on  record  showing  that  symp- 
toms of  brain-disease  may  disappear  after  considerable  lesions  of 
the  brain.  Thus,  in  a  case  of  insanity  and  epilepsy  there  was 
almost  a  complete  cure  after  a  fracture  of  the  cranium  and  the 
issue  of  a  notable  quantity  of  brain-tissue.  .  .  . 

"  An  immense  variety  of  symptoms  in  different  individuals  may 
be  caused  by  a  lesion  in  one  and  the  same  part  of  the  brain.  Symp- 
toms of  brain-disease  vary  immensely,  not  only  in  intensit}^,  as 
stated  already,  but  also  in  their  kind,  although  the  lesion  pro- 
ducing them  occupies  the  same  place.  .  .  .  The  only  rational  ex- 
planation is,  that,  in  the  same  way  that  an  irritation  of  any  peri- 
pheric nerve  may  either  be  insufficient  to  produce  a  remote  effect, 
or  quite  able,  on  the  contrary,  to  produce  the  most  varied  effects, 
a  disease  in  any  part  of  the  brain  may  also  be  the  starting-point 
of  either  an  inefficient  irritation,  or  act  by  means  of  that  irrita- 
tion on  distant  parts  and  produce  through  them  either  kind  of 
symptoms." 


174  DISEASES   OF   THE   NERVOUS   SYSTEM. 

DIAGNOSIS. 

It  is  often  impossible  to  make  an  absolute  diagnosis  in  chronic 
meningitis ;  especially  is  the  difficulty  magnified  when  we  attempt 
to  differentiate  between  the  last-named  affection  and  encephalitis, 
and  more  particularly  when  we  consider  that  these  two  affections 
sometimes  coexist. 

It  is  only  by  a  careful  study  of  its  etiology,  the  sequence  of 
symptoms,  the  course  of  the  disease,  the  prominence  of  pain  as  a 
symptom,  and  collateral  facts,  that  we  can  solve  the  diagnostic 
enigma. 

The  absence  of  marked  mental  symptoms  also  favors  a  diag- 
nosis of  meningitis ;  so  does  the  occurrence  of  delirium  and  con- 
vulsions. 

PROGNOSIS. 

The  prognosis  is  always  serious.  The  most  favorable  cases 
are  undoubtedly  those  of  specific  origin,  in  which  radical  anti- 
syphilitic  treatment  is  often  highly  beneficial. 

TREATMENT. 

Mercurials  and  iodide  of  potassium  form  our  main  reliance  in 
these  cases.  The  bromides  and  ergot  may  be  given  in  the  earlier 
stages.  The  bowels  should  be  regulated  by  laxatives.  Counter- 
irritants,  and  especially  the  chronic  pustulation  of  the  shaven 
scalp  with  croton  oil,  may  prove  of  some  service.  The  patient's 
diet  should  be  regulated.  Stimulants  should  be  eschewed.  Emo- 
tional excitement  and  mental  fatigue  should  be  guarded  against. 

An  excellent  method  of  administering  iodide  of  potassium  is 
in  concentrated  solution,  thus  : 

R  Potassii  iodidi,  ^i ; 

Aquae  destil.,  q.  s.  ad  f.^i. — M. 
S. — Each  minim  of  the  above  solution  will  represent  one  grain  of  the  salt. 
(N.B. — From  ten  to  twenty  minims  would  represent  an  average  dose,  which 
may  be  increased  a  drop  or  a  minim  each  dose  in  cases  where  a  progressive  in- 
crease in  the  dose  is  desirable.) 

CHRONIC    BASILAR   MENINGITIS. 

Probably  the  most  common  cause  of  this  disease  is  syphilis; 
alcoholism  ranks  next.  Excessive  anxiety  and  emotional  disturb- 
ances of  all  kinds  are  among;  its  alleged  causes. 


CHRONIC   CEREBRAL   MENINGITIS.  175 

Hammond  states  that  "next  in  point  of  frequency  come  at- 
mospheric vicissitudes,  blows  on  the  head,  and  attacks  of  other 
diseases,  as  scarlet  fever,  and  especially  epidemic  cerebro- spinal 
meningitis,  and  suppurative  otitis.  Men  are  more  subject  to  it 
than  women,  and  adults  more  than  children.  Frequently  no 
cause  can  be  assigned." 

SYMPTOMS. 

Headache,  as  I  have  frequently  reiterated  in  the  preceding  lec- 
tures on  the  forms  of  meningitis,  is  an  early,  frequent,  persistent, 
and  very  prominent  symptom. 

Epileptiform  attacks  very  often  coexist  with  the  cephalalgia. 
Hammond  insists  upon  this  point,  and  adds,  "  There  may  be  con- 
vulsive movements  of  a  limb,  a  group  of  muscles,  or  a  single 
muscle,  unattended  with  loss  of  consciousness.  Again,  there  may 
be  tonic  spasms  of  the  muscles  of  one  or  more  of  the  extremi- 
ties, especially  of  the  arms ;  or  the  muscles  of  the  neck  may  be 
similarly  affected,  causing  the  head  to  be  fixed  in  an  abnormal 
position.  The  individual  muscles  of  the  face  are  not  usually 
involved." 

Paralysis  sooner  or  later  occurs.  It  may  be  of  a  hemiplegic 
character,  of  the  ordinary  cerebral  type.  Facial  palsy  and  diffi- 
cult articulation  are  sometimes  noted. 

Some,  or  nearly  all,  of  the  motor  nerves  of  the  eye  may  be 
involved. 

A  common  occurrence  is  unilateral  paralysis  of  the  third  nerve, 
resulting  in  ptosis,  defective  accommodation,  diplopia,  dilatation 
of  the  pupils,  and  external  strabismus.  This  paralysis  is  con- 
ceded, by  all  authorities  with  whom  I  am  acquainted,  to  be 
particularly  characteristic  of  meningeal  and  intracranial  syphilis. 
On  this  point  I  cannot  lay  too  much  stress,  and  I  shall  advert  to 
it  again  in  subsequent  lectures.  The  paralysis  may  be  complete 
or  partial. 

Hammond  asserts  "  that  in  a  few  cases  the  only  indication  of 
the  affection  of  the  third  nerve  is  dilatation  of  the  pupils." 

Paralysis  of  the  fourth  and  sixth  nerves,  vertigo,  mental  con- 
fusion, and  aphasia,  are  frequently  encountered. 

It  has  been  my  sad  experience  to  witness  a  corroboration  of 
Hammond's  observation,  that  in  a  few  isolated  cases  pain  of  the 


176  DISEASES    OF   THE   NEEVOUS   SYSTEM. 

most  extreme  severity  and  persistency,  "  almost  driving  the  patient 
to  suicide,"  may  exist  for  a  long  time  as  the  only  symptomatic 
indication  of  a  latent  basilar  meningitis.  I  am  at  present  attending 
a  gentleman  in  whose  case  seven  prominent  physicians  were  unsuc- 
cessfully consulted,  before  he  placed  himself  under  my  care,  for  the 
above-described  condition.  I  have  treated  him  during  a  long  period 
"without  affording  him  the  slightest  relief.  Galvanism,  cinchonism, 
opiates,  the  application  of  the  thermo-cautery  to  the  nucha,  mer- 
curial preparations,  iodide  of  potassium  in  half-ounce  doses  daily, 
antipyrine,  chloral,  sulfonal,  have  all  failed  to  produce  any  miti- 
gation of  the  extreme  pain.  Three  or  four  hours  of  fitful  slumber 
have  hardly  been  procured,  so  obstinate  has  been  the  insomnia 
resulting  from  the  intense  headache.  At  no  time  has  he  complained 
of  localized  cephalalgia,  which,  on  the  contrary,  has  been  erratic. 
Its  diffusion  has  been  as  remarkable  as  its  persistent  duration. 
There  have  been  no  evident  remissions  of  the  headache.  It  has 
been,  perhaps,  more  particularly  prominent  in  the  occipital  and 
frontal  regions,  sometimes  extending  to  the  face.  Repeated  ex- 
amination has  failed  to  detect  optic  neuritis.  There  is  entire 
absence  of  all  other  symptoms.  There  is  no  specifie  history  of 
any  kind.  The  case  is  a  real  opprobrium  7nedicorum,  as  far  as 
tentative  therapeutic  results  are  concerned.  It  has  excited  my 
deej)  sympathy ;  I  really  dread  the  patient's  visits,  and  yet  I 
doubt  not  that  it  is  one  of  those  exceptional  cases  of  chronic  basilar 
meningitis  so  graphically  described  by  Hammond. 

Anaesthesia,  limited  or  diffused,  accompanied  or  not  by  disturb- 
ances of  the  kinesodic  zone,  may  or  may  not  appear. 

Disturbances  of  vision  are  frequent,  often  appear  early,  and  may 
be  of  a  general  or  a  special  character. 

Disturbances  of  the  cranial  nerves  are  very  common.  Optic 
neuritis  often  coexists.  Vision  is  sometimes  entirely  lost.  Hear- 
ing may  be  impaired  or  destroyed.  The  mind  is  not  primarily 
affected  to  a  notable  degree.  Mental  depression  not  infrequently 
manifests  itself,  and  the  processes  of  intellection  are  at  times 
defective. 

INIutability  of  symptoms  becomes  evident  when  there  exists  a 
transferrence  of  seat  in  chronic  basilar  meningitis.  This  change 
of  location  is  expressed  by  alterations  of  the  symptoms,  which 
then  become  migratory  and  are  somewhat  modified. 


CHRONIC   CEREBRAL   MENINGITIS.  177 

ANATOMICAL.  APPEARANCES. 

The  inflammation  in  chronic  basilar  meningitis  is  miicli  more 
limited  and  circumscribed  than  in  chronic  vertical  meningitis,  and, 
as  Hammond  remarks,  "  it  may  be  restricted  to  a  portion  of  the 
membranes  not  larger  than  a  dime." 

The  membranes  are  usually  thickened  and  more  or  less  opaque. 
More  or  less  serum  will  be  found  in  some  places  ;  in  others,  a  thick, 
gummy,  or  puriform  collection.  The  exudations  may  become 
organized,  and  are  sometimes  adherent.  The  injection  of  the 
pia-arachnoid  is  in  some  places  intense.  ,  The  effusion  may  be 
sub-arachnoidean,  may  lodge  in  the  meshes  of  the  pia  mater,  or 
may  produce  ventricular  distention. 

The  pia  mater  sometimes  contains  deposits  of  a  whitish-gray 
fibrinous  substance,  following  the  course  of  some  of  the  cerebral 
vessels,  and  Hammond  asserts  that  it  is  particularly  found  "  over 
the  chiasma  of  the  optic  nerves,  the  tubercula  mammillaria,  and 
the  anterior  perforated  spaces." 

The  optic  and  olfactory  nerves  may  be  atrophied. 

"When  the  arachnoid  and  the  pia  are  adherent,  the  latter  mem- 
brane is  in  some  instances  so  firmly  glued  to  the  cortical  substance 
of  the  brain  also  that  it  cannot  be  separated  from  it  without 
laceration. 

Whether  the  exudation  be  fibrinous,  serous,  or  purulent,  it  is 
generally  situated  in  the  meshes  of  the  pia  mater,  in  the  layers  of 
the  arachnoid,  or  in  the  sub-arachnoid  spaces ;  but  in  chronic 
basilar  meningitis  it  is  more  particularly  found  at  the  base  of  the 
brain,  and,  as  Hammond  observes,  "  its  usual  situations  are  the 
chiasma  of  the  optic  nerves,  along  the  course  of  these  nerves,  on 
the  tuber  cinereum,  the  corpora  mammillaria,  and  between  the 
crura  cerebri.  Sometimes  it  extends  anteriorly  along  the  course 
of  the  olfactory  nerves,  laterally  into  the  fissure  of  Sylvius,  and 
posteriorly  as  far  as  the  pons  Varolii  and  medulla  oblongata." 

There  can  be  no  doubt  that  chronic  basilar  meningitis  is  fre- 
quently of  syphilitic  origin,  although  Gintrac,  as  quoted  by  Ham- 
mond, "  doubts  its  existence,  though  he  admits  its  possibility :" 
the  latter  authority,  however,  does  not  concur  in  this  opinion. 

Hammond  states  that  "  in  the  syphilitic  form  of  the  disease  it 
is  a  matter  of  some  doubt  whether  the  gummy  exudation  is  the 

12 


178  DISEASES   OF   THE   NERVOUS   SYSTEM. 

result  of  a  sj^ecific  inflammation  of  the  membranes,  or  wliether  the 
inflammation  is  excited  by  the  presence  of  the  new  formation." 

Fox,  quoted  by  Hammond,  states  it  as  his  opinion  "  that  it  is 
at  best  an  open  question  whether  meningitis  ever  occurs  indepen- 
dently of  syphilis,  rheumatism,  alcoholic  poison,  tubercle,  anaemia, 
or  mechanical  irritations." 

Gummy  tumors  are  usually  found  at  the  hose  of  the  brain. 
They  may  be  either  circumscribed  or  diffused ;  "  but  ordinarily 
they  are  more  diffused,  and  are  accompanied  with  the  phenomena 
of  inflammation,  a  fact  which  seems  to  distinguish  them  from 
the  true  tumor,"  says  Hammond,  who  follows  Virchow  in  regard- 
ing this  condition  as  a  "  gummy  inflammation." 

The  seat  of  syphilitic  basilar  inflammation  is  the  same  as  that 
of  the  other  varieties  of  chronic  basilar  meningitis.  "  Hence  it 
is,"  reiterates  Hammond,  "  that  the  nerves  lying  at  the  base  of  the 
brain,  and  especially  the  third  -pair,  are  so  liable  to  be  implicated. 
This  latter,  from  its  exposed  situation,  running,  as  it  does,  from  the 
crura  cerebri  to  the  orbit,  can  scarcely  escape  being  involved  in  the 
morbid  process."  Focal  chronic  meningitis  is  usually  syphilitic, 
and  is  often  associated  with  disease  of  the  arteries.  The  nerve- 
sheaths  are  often  reddened.  Minute  hemorrhages  may  occur 
therein,  and  the  fibres  may  be  degenerated.  The  inner  surface 
of  the  dura  mater  may  be  congested,  covered  with  lymph,  and 
adherent  to  the  pia-arachnoid.  The  choroid  plexus  and  velum 
interpositum  may  be  inflamed.  The  third  ventricle,  aqueduct, 
and  fourth  ventricle  are  often  distended  ;  their  communication  is 
often  obliterated  by  accumulations  of  lymph  in  the  neighborhood 
of  the  aqueduct  of  Sylvius  and  valve  of  Vieussens. 

PROGNOSIS. 

Like  all  other  forms  of  meningitis,  chronic  basilar  meningitis 
is  very  fatal,  and  its  prognosis  is  most  unfavorable.  Syphilitic 
cases,  if  subjected  early  to  an  earnest  and  radical  specific  treat- 
ment, frequently  improve,  under  circumstances  apparently  most 
unpropitious. 

Alcoholic  cases,  if  the  lesions  be  not  too  far  advanced,  may 
improve,  provided  the  habit  be  controlled.  Traumatic  cases  are 
generally  fatal. 

"When  the  disease  is  due  to  mental  and  emotional  causes,  it  is 


CHRONIC   CEREBRAL   MENINGITIS.  179 

susceptible  of  amelioration,  if  such  baneful  influences  be  regulated 
or  abrogated. 

Recurrence  of  the  attacks,  their  duration,  and  age,  especially 
the  two  extremes  of  life,  all  bear  unfavorably  upon  the  prognosis. 
It  is  especially  asserted,  by  Hammond  and  other  writers,  that 
when  the  disease  is  the  result  of  an  extension  of  aural  inflamma- 
tion, an  unfavorable  termination  is  to  be  anticipated. 

DIAGNOSIS. 

The  existence  of  cerebral  tumors  is  betrayed  by  symptomatic 
phenomena  very  apt  to  mislead  in  the  diagnosis  of  this  disease ; 
this  point  will  be  especially  considered  in  our  lecture  on  such 
tumors.  We  agree  with  Hammond  that  "  the  symptoms  of 
chronic  basilar  meningitis  are  less  pronounced  than  those  of  tumors 
at  the  base  of  the  brain,  while,  at  the  same  time,  they  are  ordi- 
narily developed  with  greater  rapidity.  Another  mark  of  difler- 
ence  is  the  fact  that  tumors  non-syphilitic  in  character  do  not 
yield  to  remedial  measures,  while  chronic  basilar  meningitis  often 
does,  and  is  generally  mitigated  by  proper  treatment." 

"  Chronic  softening,  arising  from  thrombosis  of  the  basilar 
arteries  and  diseases  of  the  capillaries,  is  sometimes  confounded 
with  chronic  basilar  meningitis."     (Hammond.) 

Virchow,  as  quoted  by  Hammond,  "  goes  so  far  as  to  doubt  if, 
even  where  after  death  we  find  only  meningitis,  the  condition  has 
not  been  preceded  by  a  gummatous  aifection  which  has  disap- 
peared." 

TREATMENT. 

Mercury,  the  iodide  and  bromide  of  potassium,  and  ergot  are 
indicated  in  the  treatment, — the  two  latter  in  the  earlier  stages. 
Electricity  and  strychnine  may  be  resorted  to  in  the  paralytic 
complications  of  subsequent  and  more  advanced  stages.  In  syphi- 
litic cases  mercury,  especially  by  inunction,  should  be  systemati- 
cally administered.  Mercury  will  prove  beneficial  in  proportion 
to  the  recency  of  the  syphilitic  manifestations.  The  dose  of 
iodide  of  potassium  in  these  cases  should  be  gradually  increased 
to  half  an  ounce  or  an  ounce,  or  even  more,  daily.  It  should 
be  administered  in  a  goblet  of  milk,  to  prevent  gastric  irritation. 
In  septic  meningitis,  Gowers  extols  the  perchloride  of  iron. 


180  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

GENEEALITIES. 

In  chronio  ahoholie  meningitis,  which  affects  chiefly  the  con- 
vexitj,  the  most  prominent  symptoms  are  headache,  slight  optic 
neuritis,  more  or  less  delirium,  and  mental  failure.  This  disease 
runs  a  very  chronic  course,  and  its  symptoms  are  complicated  with 
those  proper  to  alcoholism. 

In  chronic  meningitis  of  the  syphilitie  variety,  Gowers  says 
that  "the  inflammatory  tissue  has  undergone  fibrous  transforma- 
tion, and  a  thick  layer  of  tissue,  tendinous  or  cartilaginous  in 
aspect,  extends  over  a  certain  region,  more  often  at  the  base  than 
at  the  convexity,  surrounding  and  compressing  the  nerves,  and 
uniting  the  various  membranes.  The  thickness  of  the  layer  may 
be  as  much  as  a  third  of  an  inch ;  the  dura  mater  is  often  also 
thickened." 

The  focal  form  of  inflammation  in  chronic  meningitis  in  adults 
is  nearly  always  syphilitic. 

I  fully  concur  with  Gowers  that  "  in  such  a  case  it  is  useless 
cruelty  to  suggest  to  a  husband,  by  questions  regarding  his  past 
history,  that  he  may  be  the  unconscious  cause  of  his  wife's  malady. 
It  is  unlikely  that  by  such  questions  syphilis  can  be  absolutely  ex- 
cluded, and  unless  it  can  be  excluded  the  anti-syphilitic  treatment 
in  such  a  case  is  the  first  duty  of  the  practitioner.  Moreover, 
if  syphilis  can  be  excluded,  the  treatment  suitable  for  syphilis 
remains  the  most  promising  for  a  simple  inflammation." 

"  The  pia-arachnoid  differs  from  most  other  membranes  that 
enclose  viscera,  in  its  separation  into  two  layers.  Nevertheless,  it 
is  commonly  regarded  as  a  serous  membrane,  and  it  presents  some 
analogies  to  other  serous  membranes  in  its  pathological  liability, 
but  also  wide  diflerences  from  them.  Like  the  pleura,  it  is  prone 
to  spontaneous  inflammation,  but  the  most  common  cause  of 
primary  pleurisy,  exposure  to  cold,  seems  to  have  little  influence 
in  exciting  meningitis.  It  is  the  seat  of  specific  processes  more 
frequently  than  any  other  serous  membrane,  and  this,  together 
with  its  liability  to  suffer  in  states  of  blood-poisoning,  must  be 
regarded  as  its  chief  pathological  characteristic.  The  process  of 
inflammation  also  presents  some  peculiarities  in  the  cerebral  mem- 
brane. The  tendency  to  the  formation  of  lymph  is  smaller,  and 
of  pus  is  greater,  than  in  the  case  of  the  pleura  or  the  pericardium. 


CHEONIC   CEREBRAL   MENINGITIS.  181 

Embolic  processes  may  play  a  part  in  the  generation  of  some  forms 
of  septicaemic  inflammation,  but  it  is  probable  that  the  circulation 
of  the  septic  matter  in  the  blood,  not  necessarily  organisms,  suffices 
to  excite  in  the  membranes  the  inflammation  to  which  they  are 
prone.  The  origin  of  the  miliary  tubercles  of  the  meninges  is  a 
problem  that  belongs  to  general  pathology."     (Gowers.) 

In  chronic  cerebral  meningitis  the  significance  of  the  head- 
ache depends  upon  its  intensity,  persistency,  and  diffusion.  To 
use  a  paradoxical  expression,  its  diffusion  is  in  direct  correlation 
with  its  fixity.  Delirium,  spontaneous  vomiting,  and  convulsions 
are  often  prominent  and  early  symptoms,  in  conjunction  with 
headache. 

The  •  symptoms,  of  course,  vary,  and  but  too  frequently  are 
protean  in  their  manifestations ;  there  is  no  symptom  of  menin- 
gitis that  may  not  at  times  be  absent,  and  it  may  safely  be  stated 
that  there  is  absolutely  no  pathognomonic  symptom  of  chronic 
meningitis. 

Attention  to  the  etiology  of  the  disease  is  of  paramount  diag- 
nostic importance. 

In  cases  where  there  exists  a  tubercular  heredity,  a  meningitis 
Avill  almost  certainly  be  of  the  prevailing  diathetic  type. 

Gowers  says,  "  the  discovery  of  tubercles  of  the  choroid  renders 
the  nature  of  the  inflammation  certain." 

The  same  author  remarks,  speaking  of  chronic  meningitis  in 
general,  that  "  if  the  inflammation  is  at  the  convexity,  the  proba- 
bility of  its  tubercular  nature  is  considerable  in  childhood  and 
youth,  but  in  adult  life  such  inflammation  is  probably  not  tuber- 
cular. Under  twenty  years  of  age  there  is  a  presumption,  in 
the  absence  of  other  causal  indications,  that  any  meningitis  is  of 
tubercular  origin,  but  over  forty  there  is  a  presumption  against 
this,  which  increases  in  weight  as  life  advances." 

It  is  well  to  bear  in  mind  that  in  cases  of  acute  general  diseases 
in  which  head-symptoms  exist  we  shall  avoid  the  danger  of  con- 
founding these  with  the  symptoms  of  true  meningitis  if  ^ve 
remember  Gowers's  quotauon  from  Sir  William  Jenner,  that 
"  when  they  are  the  result  of  pyrexia,  the  headache  ceases  when 
the  delirium  begins ;  in  meningitis  the  headache  continues  and 
coexists  with  the  delirium." 

It  is  also  well  to  bear  in  mind  the  fact  that  while  optic  neuritis 


182  DISEASES   OF   THE   NERVOUS   SYSTEM. 

sometimes  accompanies  acute  specific  diseases^  it  is  more  apt  to 
follow  in  their  train  than  to  coexist  with  them. 

Optic  neuritis,  when  complicating  meningitis,  is  usually  much 
less  intense  than  in  cases  of  tumor. 

Meningitis  has  sometimes  been  confounded  with  hysteria.  This 
multiform  aifection  may  be  associated  with  any  organic  disease  of 
the  nervous  system,  but  must  be  recognized  as  a  complication  of 
meningitis  or  reversely,  under  the  guidance  of  broad  principles 
of  diagnosis.  This  point  has  been  most  ably  discussed  by  Dr. 
Seguin,  of  New  York,  in  a  recent  able  monograph.  "Where  doubt 
exists,  the  development  of  the  symptoms  of  organic  disease  must 
be  carefully  watched  for  and  minutely  scrutinized.  Fever  and 
optic  neuritis,  when  present,  will  be  symptoms  of  material  import 
in  making  a  diagnosis. 

Gowers  asserts  that  "  strabismus  in  hysteria  is  always  convergent 
and  attended  by  spasmodic  contraction  of  the  pupils.  Divergent 
strabismus  or  inequality  of  pupil  is  certain  evidence  of  organic 
disease,  and  as  much  so  if  it  is  transient  as  if  it  is  permanent. 
Retention  of  urine  may  be  due  to  hysteria,  but  incontinence 
never  is." 

Gowers  cautions  us  to  avoid  mistakes  in  the  differential  diag- 
nosis between  chronic  cerebral  meningitis  and  acute  double  otitis 
of  children,  in  which  we  may  observe  headache,  vomiting,  fever, 
delirium,  giddiness,  convulsions,  and  deafness.  He  suggests  that 
in  such  cases  the  labyrinth  is  chiefly  affected.  Care  in  diagnosis 
in  such  a  contingency  is  all  the  more  necessary  because  in  some 
cases  of  acute  double  otitis  optic  neuritis  may  be  developed.  He 
adds  that  "  the  difficulty  is  increased  by  the  fact  that  the  internal 
ear  may  be  inflamed  secondarily  to  meningitis.  Such  secondary 
otitis  has  been  observed  in  cerebro-spinal  meningitis,  but  it  is 
very  rare." 

The  presence  or  absence  of  optic  neuritis  in  meningitis  and  in 
brain-tumors  does  not  always  throw  as  much  light  upon  the  case 
as  we  might  wish. 

"  The  significance  of  optic  neuritis  as  a  diagnostic  and  prognostic 
sign  in  cases  of  cerebral  tumors  is  alluded  to  by  Mr.  Horsley  in 
his  interesting  communication,  in  which  he  details  his  experience 
in  cerebral  surgery.  In  two  of  the  three  cases  on  which  he  oper- 
ated it  appears  that  there  was  no  optic  neuritis,  and  in  these  two 


CHEONIC  CEREBRAL.  MENINGITIS.  183 

recovery  ensued.  In  the  third,  a  case  of  cerebellar  tumor,  there 
was  optic  neuritis,  and  this  patient  died.  To  these  may  be  added, 
besides  those  reported  in  this  paper,  Dr.  Hughes  Bennett's  and 
Mr.  Godlee's  case,  in  which  optic  neuritis  was  present,  and  a  case 
of  cerebellar  tumor  with  neuritis  recently  operated  on  by  Mr. 
Bennett  May.  Both  of  these  were  unsuccessful.  Thus,  out  of 
five  cases,  the  two  which  had  no  optic  neuritis  recovered,  while  the 
three  which  had  optic  neuritis  died.  It  may  be  that  this  coin- 
cidence is  accidental,  for  recoveries  take  place  in  some  cases  of 
head-injuries  and  cerebral  abscesses  in  which  neuritis  has  occurred  ; 
but  still  its  presence  must  be  taken  to  indicate  some  complica- 
tion which  is  probably  harmful,  and  makes  it  important  that, 
if  possible,  tumors  of  the  brain  should  be  recognized  before  the 
onset  of  optic  neuritis,  and,  therefore,  without  its  diagnostic  aid."  * 
The  same  may  be  said  of  meningitis,  cerebral  abscess,  and  other 
intracranial  affections,  in  which  evidences  of  optic  neuritis  are  so 
frequently  and  carefully  sought  for  by  investigators. 

It  should  always  be  borne  in  mind  that  meningitis  may  be 
excited  as  a  result  of  suppm-ation  in  the  middle  ear,  while  as 
yet  no  discharge  whatever  has  occurred. 

*  Surgery  of  the  Brain,  Senn,  Sajous's  Annual  of  the  Universal  Medical 
Sciences,  1888. 


LECTURE  XII. 

INSANITY. 

Insanity  a  Disease  of  the  Brain — Its  Origin — Location — Predisposition — Insanity  He- 
reditary— Definition — Unconscious  Cerebration — Moral  Insanity ;  Examples — Rules 
for  AscertaLnLng  Insanity. 

Gentlemen, — I  propose  to-niglit  to  enter  upon  the  subject 
of  insanity.  We  must  not  leave  this  disorder  unstudied  on  ac- 
count of  its  infrequency,  for  the  young  practitioner  must  expect 
and  be  prepared  to  meet  all  disorders.  It  is  not  a  disease  of  the 
mind,  but  a  peculiar  affection  of  the  brain.  You  will  undoubt- 
edly be  called  upon  to  express  your  views  of  its  nature,  and  will 
naturally  be  expected  to  possess  some  knowledge  of  its  leading 
features.  The  study  of  insanity  is  a  matter  peiiaining  to  the 
general  practitioner,  for  this  malady  is  as  distinctly  a  disease  of 
the  brain  as  any  other  affection  of  that  organ.  It  consequently 
demands  his  attention  as  cogently  as  any  other  disorder  of  the 
human  body.  Though  a  true  disease  of  the  brain,  it  does  not 
invariably  originate  in  that  organ ;  indeed,  it  may  start  almost 
anywhere  else,  as  in  the  diseased  uterus  in  the  female,  or  in  some 
morbid  condition  of  the  colon,  and  in  either  case  may  disappear 
if  proper  treatment  be  addressed  to  its  source. 

When  a  man  is  insane  there  is  always  a  disturbance  of  the 
normal  working  powers  of  the  brain.  Insanity  may  have  the 
greatest  multiplicity  of  primary  causes.  In  the  majority  of  cases, 
I  believe,  insanity  originates  at  a  greater  or  less  distance  from  the 
brain,  and  hence  is  mostly  a  secondary  affection,  and  but  rarely 
idiopathic. 

This  affirmation  constitutes  one  step  towards  a  proper  elucida- 
tion of  this  subject,  for  it  implies  that  insanity  is  not  necessarily 
a  stigma,  as  was  formerly  supposed ;  nor  is  it,  metaphysically 
speaking,  a  disorder  of  the  mind,  with  accompanying  mental  dis- 
turbances of  a  mysterious  character.  It  is  an  affection  of  the 
184 


INSANITY.  185 

brain,  which,  though  not  always  originating  in  that  organ,  inva- 
riably has  its  seat  there. 

You  will  not  find  it  difficult  to  appreciate  these  facts  if  you 
recollect  that  the  brain  is  the  supreme  centre,  presiding  over  all 
the  other  parts  of  the  nervous  system  and  of  the  animal  economy. 
Indeed,  we  can  hardly  conceive  of  any  constituent  atom  of  the 
body,  no  matter  where  found,  which  is  not  in  more  or  less  inti- 
mate relation  with  the  brain  or  the  cerebro-spinal  system  of  nerves. 
It  presides  over  multitudinous  atoms,  its  influence  is  felt  through- 
out the  body,  and  there  is  not  a  muscle,  nerve,  artery,  or  vein, 
nor  even  the  smallest  histological  element  in  tlie  human  system, 
which  is  not  permeated  by  the  peculiar  nervous  force  or  influence 
emanating  from  tlie  "  supreme  cerebral  ganglia."  How  easy, 
then,  is  it  to  understand  tliat  the  functions  of  the  brain  may  be 
more  or  less  impaired  by  the  presence  of  disease  there  or  else- 
where, especially  where  any  predisposition  to  insanity  exists ! 

In  all  disorders  leading  to  insanity  this  predisposition  undoubt- 
edly exercises  a  great  influence  and  plays  a  most  important  rdle. 
That  it  is  inherent  in  many  instances  there  can  be  no  doubt.  In 
insanity,  as  in  other  maladies,  a  great  many  facts  are  manifest 
which  we  are  unable  to  interpret  without  an  assumption  of  predis- 
position or  heredity.  Why  should  one  member  of  a  family  die 
of  phthisis,  and  another,  placed  in  the  same  conditions,  be  un- 
affected ?  Schroeder  van  der  Kolk  has  conclusively  proved  how 
insanity  and  phthisis  pulmonalis  alternate  in  the  same  individual. 
Or,  in  scarlatina,  independently  of  its  contagious  elements,  why  is 
it  that  one  child,  though  unprotected,  may  be  exposed  with  im- 
punity, and  another  will  contract  the  malady  in  its  malignant 
form  and  thereby  perish  ?  Or,  again,  why  is  it  that  after  vacci- 
nation one  person  may  never  again  be  susceptible  to  the  virus,  and 
another  will  be  re-vaccinated  almost  at  pleasure  and  vaccinia 
readily  reproduced  ?  In  re- vaccinating  persons  in  large  commu- 
nities, I  have  several  times  been  struck  by  the  fact  that  the  opera- 
tion was  often  successful  in  those  who  had  been  inoculated  "  in 
the  old  country"  or  were  distinctly  pitted  with  pock-marks  from 
varioloid.  Why  should  this  be?  It  is  probably  on  account  of 
a  marked  predisposition  existing  in  the  system.  Why  should  one 
person  be  effectually  protected  by  one  attack  of  small-pox  and 
another  die  of  a  third  attack,  as  happened  in  London  in  a  case 


186  DISEASES   or   THE   NERVOUS  SYSTEM. 

related  by  Dr.  "Watson  ?  Such  an  occurrence  must  undoubtedly 
be  referred  to  variable  predisposition.  So  it  is  in  insanity.  Some 
individuals  are  very  much  predisposed  to  it,  and  labor  under  a 
highly  unstable  condition  of  the  nervous  system.  In  many  cases, 
such  being  the  condition,  the  patient  goes  mad,  while  another 
person,  subjected  to  exactly  the  same  influences  and  conditions, 
will  not  experience  the  slightest  variation  in  the  performance  of 
his  intellectual  functions. 

Upon  inquiry  into  the  history  of  the  insane,  you  will  generally 
find  that  the  predisposition  does  not  originate  with  the  individual, 
but  existed  prior  to  himself;  that  is,  it  is  mostly  hereditary  and 
transmitted,  and  this  tendency  to  insanity  is  an  heirloom.  You 
often  hear  insanity  spoken  of  as  a  mental  aberration,  lunacy,  a 
condition  of  non  compos  mentis,  etc. ;  but  the  comprehensive  term 
insanity  is  the  best  of  all.  Insanity  literally  means  deprivation  of 
reason, — deviation  from  mental  health, — unsoundness  of  mind. 
Now,  is  it  practicable  to  formulate  an  exact  definition  of  insanity  ? 
We  will  more  particularly  answer  this  question  in  our  next  lec- 
ture, when  we  revert  to  this  subject.  Can  a  line  between  insanity 
and  reason  be  drawn  so  sharply  that  all  the  phenomena  found  on 
one  side  shall  be  compatible  with  reason,  and  those  on  the  other 
with  insanity  ?  This  is  impossible,  and,  as  a  great  author  says, 
"  The  shades  of  variation  in  eccentricity,  between  sanity  and  in- 
sanity, are  so  slight  and  numerous  that  it  is  exceedingly  difficult 
to  state  where  reason  ends  and  insanity  begins."  This  you  might 
perhaps  have  had  occasion  to  exemplify,  as  you  may  have  a  friend 
in  whom  at  times  you  have  noticed  very  strange  actions.  Some- 
times you  will  think  that  if  you  were  not  acquainted  with  the 
man  you  would  suppose  him  to  be  crazy,  or  not  be  surprised  if 
some  day  he  should  lose  his  mind.  This  would  be  the  result  of 
observing  that  some  of  his  actions  were  not  apparently  compatible 
with  the  integrity  of  his  mental  faculties ;  while  his  deportment 
at  other  times  might  entirely  remove  your  apprehensions.  Such 
people  may  be  said  to  live  upon  the  "  border-land  of  insanity,"  and 
are  very  apt  occasionally  to  cross  the  line  and  return ;  occasionally 
they  are  seemingly  crazy,  at  other  times  they  are  not.  Learned, 
eminent,  and  practical  men  "  cross  the  line"  sometimes,  and  make 
short  excursions  into  the  labyrinths  of  intellectual  aberration.  At 
all  events,  there  is  in  some  people  a  peculiar  predisposition  to  get 


INSANITY.  187 

over  the  line,  and  their  peregrinations  and  rapid  transitions  mys- 
tify medical  experts.  No  matter  how  much  experience  you  may 
possess,  you  will  be  occasionally  unable  to  determine  the  status  of 
such  cases.  Under  certain  circumstances,  fortunately  rare,  it  may 
take  a  long  time.  Months,  even,  may  pass  before  you  will  be  able 
to  arrive  at  a  definite  conclusion,  and  occasionally  you  may  be 
baffled  after  all.  This  may  seem  strange  at  first  sight,  but  after 
a  study  of  the  various  phenomena  and  difficulties  of  the  subject  it 
will  not  appear  so  remarkable. 

Did  you  ever  see  two  persons  between  whom  not  the  slightest 
difference  existed  of  feature,  countenance,  or  appearance  ?  Even 
the  voice  presents  a  dissimilarity  in  different  persons,  being  coarse 
and  harsh  in  some,  soft  and  melodious  in  others.  Understand, 
that  as  faces  and  voices  differ,  so  are  mental  characteristics  distinct. 
Again,  if  persons  vary  so  much  in  their  physical  and  mental  ca- 
pacities and  equalities  in  health,  how  much  more  will  they  disagree 
when  affected  by  disease  !  Besides  this,  great  changes  and  varie- 
ties of  development  are  produced  in  sane  minds  under  different 
influences  and  circumstances.  The  mental  faculties  become  blunted 
by  neglect  of  education,  or  they  may  be  constantly  improved  and 
developed  by  mental  gymnastics.  In  men  who  habitually  study 
and  think,  there  is,  figuratively  speaking,  considerable  mental  ab- 
sorption constantly  and  automatically  occurring,  by  what  Dr.  Car- 
penter terms  "unconscious  cerebration.'^  Some  authors  contend 
that  the  most  brilliant  thoughts  often  result  from  mental  activity 
of  this  t}'pe.  Have  you  never  involuntarily  thought  of  some- 
thing while  your  attention  was  engaged  on  other  subjects,  and, 
struck  by  the  pertinency  of  the  thought,  immediately  noted  it,  in 
order  to  retain  it  in  your  memory  ?  Or  have  you  never  retired, 
after  assiduously  striving  to  master  a  perplexing  subject,  at  last 
abandoning  it  in  despair,  to  seek  repose  and  to  recuperate  your 
energies  for  renewed  efforts,  and  upon  awaking  next  morning  after 
a  sound  sleep,  found  yourself  clear-headed  and  bright,  and  in  per- 
fect possession  of  what  a  few  hours  before  you  had  quite  despaired 
of  attaining?  This  is  "unconscious  cerebration."  You  were 
appropriating  knowledge  unconsciously,  and  after  an  invigorating 
rest  the  mind  manifested  what  you  had  thoroughly  acquired  with- 
out perceiving  it.  It  is  through  the  channels  of  sense  that  man  is 
educated,  by  a  perception  effected  in  the  cerebral  convolutions  of 


188  DISEASES   OF   THE   NERVOUS  SYSTEM. 

whatever  the  senses  may  have  transmitted ;  which  perception 
always  involves  a  working  of  the  cortical  cells,  and  in  proportion 
as  we  cultivate  their  working  power  we  add  to  their  capacity.  As 
the  mind  is  capable  of  cultivation,  so  are  the  individual  senses ; 
and,  by  the  laws  of  compensation,  one  sense  may  supply  a  lost 
one,  as  a  blind  man's  hearing  or  touch  may  become  preternaturally 
developed.  But  suppose  a  man  to  have  arrived  at  the  age  of 
thirty  without  having  used  his  senses,  and  that  all  at  once  they 
be  fully  developed,  what  would  be  the  result?  He  would  be  an 
idiot ;  never  having  been  able  to  cultivate  his  senses,  he  could  not 
appreciate  their  working,  and  time  must  necessarily  elapse  before 
he  could  be  enlightened  by  them.  I  cannot  give  a  distinct  defi- 
nition of  insanity  that  would  be  comprehensive,  because  of  its 
protean  character,  on  account  of  the  great  and  almost  infinite 
dissimilarity  normally  existing  between  the  minds  of  diiferent 
individuals,  which  will  be  greatly  widened  under  pathological 
conditions.  Insanity  in  one  person  may  produce  actions  not 
unlike  those  of  the  brute,  while  in  another  it  may  lead  to  actions 
of  a  very  diiferent  character.  So  that  there  can  be  no  constant, 
pathognomonic  phenomena  which  may  be  said  to  be  attendant 
upon  mental  alienation.  Of  course  we  have  certain  classifications, 
but  some  of  the  manifestations  of  insanity  will  not  admit  of  any 
special  grouping.  I  believe  that  upon  the  witness-stand  you  may 
prudently  decline  to  attempt  any  definition  of  insanity,  for  reasons 
just  mentioned. 

"  Insanity  is,"  according  to  Sheppard,  "  a  disease  of  the  neurine 
batteries  of  the  brain."  This  definition  has  at  least  one  merit : 
it  will,  he  says,  "  puzzle  the  lawyers."  It  sometimes  happens 
that,  when  medical  evidence  is  required  in  court,  the  legal  gentle- 
men, being  very  shrewd,  possessing  a  knowledge  of  medical  juris- 
prudence and  perhaps  some  smattering  of  medical  science,  seek 
definitions  for  their  own  purposes,  knowing  how  incomplete  and 
unsatisfactory  they  necessarily  are,  and  will  afterwards  endeavor 
to  entangle  you  in  their  mazes.  For  these  very  considerations, 
the  more  concise  and  explicit  you  are  in  your  testimony,  the  better. 
Another  definition  is  that  of  Maudsley,  who  states  that  "  insanity 
is  a  morbid  derangement,  generally  chronic,  of  the  supreme  cere- 
bral centres,  the  gray  matter  of  the  convolutions,  or  the  intellec- 
iorium  commune,  giving  rise  to  perverted  feeling,  defective  or 


INSANITY.  •        189 

erroneous  ideation,  and  discordant  conduct,  conjointly  or  sepa- 
rately, and  more  or  less  incapacitating  the  individual  for  his  due 
social  relations."  Now,  in  some  respects  this  definition  is  defi- 
cient ;  it  is  not  sufficiently  comprehensive,  possessing  some  flaws, 
and  not  covering  all  cases.  Still,  it  has  undoubted  advantages, 
because  it  states — first,  where  the  disease  is  located,  and,  secondly, 
that  the  disease  is  usually  chi'onic.  According  to  Van  der  Kolk, 
all  insanity  is  acute  which  has  not  existed  over  three  months. 
We  are  not  to  infer  from  IMaudsley's  reference  to  the  fact  of  the 
ailment  being  usually  chronic  that  it  was  not  originally  acute,  but 
simply  that  a  physician  is,  as  a  rule,  called  to  treat  it  after  the 
condition  has  become  more  or  less  chronic.  This  division  of  the 
different  results  of  insanity  is  also  in  accordance  with  the  best 
division  of  the  mind, — that  is,  will,  in  relation  to  those  parts 
giving  rise  to  the  phenomena  of  action;  feeling,  in  relation  to 
those  parts  giving  rise  to  the  phenomena  of  emotions  ;  and  idea- 
tion, in  relation  to  those  parts  giving  rise  to  cognition. 

Hence  it  follows  that  a  man  may  be  insane  in  his  icords,  as 
evidence  of  a  perverted  manifestation  of  intellect;  or  in  his  emo- 
tions, as  expressive  of  a  morbid  state  of  those  parts  which  preside 
over  the  development  of  his  feelings;  or  in  his  actions,  as  ex- 
pressive of  disorder  of  that  portion  of  the  brain  connected  with 
the  phenomena  of  volition;  or  there  may  be  insanity  exhibited  in 
his  actions,  emotions,  and  ideas,  conjointly ;  one,  or  the  combi- 
nation of  two,  or  all  the  three  forms  of  deranged  manifestations 
just  described,  may  be  present. 

Man  is  often  said  to  suffer  from  moral  Insanity,  which  Is  asserted 
to  be  an  affective  variety,  referring  exclusively  to  the  development 
of  irregular  emotions,  as  opposed  to  the  perversion  of  the  purely 
intellectual  faculties, — there  being  in  moral,  affective,  or  pathetic 
disorders  a  disturbance  of  the  moral  faculties  only.  In  former 
years  I  advocated  this  distinction ;  but  of  late  I  have  had  reason 
to  modify  the  views  I  so  long  taught,  and  am  now  convinced  that 
all  cases  of  moral  insanity,  closely  scrutinized,  will  present  evi- 
dences of  imperfect  ideation,  superadded  to  the  derangement  of  the 
affective  faculties.  The  point  to  recollect  for  the  present  is,  that 
a  person  may  be  insane  in  one,  two,  or  three  forms  of  manifesta- 
tion. Sometimes  it  is  difficult  to  determine  the  existence  of  in- 
sanity, because  some  Individuals  possess  a  remarkable  control  over 


190  DISEASES   OF   THE   NERVOUS  SYSTEM. 

themselves,  perhaps  being  designing  and  deceitful ;  others,  pre- 
senting some  suspicious  symptoms,  will  talk  coherently  and  intel- 
ligently, often  puzzling  experts  as  to  their  actual  psychological 
status.  You  see,  therefore,  that  a  man  need  not  be  a  raving 
maniac  in  order  to  be  insane ;  he  may  be  very  courteous,  intelligent, 
polished,  and  affable,  and  still  be  hopelessly  crazy. 

I  recollect  two  interesting  cases,  which,  in  this  connection,  I  will 
relate  to  you.  The  first  was  that  of  a  man  subjected  to  a  com- 
mission de  lunatico  inquirendo.  All  the  experts  who  knew  him 
swore  that  he  was  insane.  But  he  contended  that  he  knew  much 
more  than  the  doctors  did,  at  least  about  his  own  case.  He  wished 
to  address  the  jury,  was  permitted  to  do  so,  and  made  a  most  bril- 
liant and  persuasive  speech ;  after  which,  of  course,  the  jury 
declared  that  he  was  not  insane,  and  consequently  he  was  per- 
mitted to  return  home.  The  very  first  day  of  his  enjoyment  of 
liberty,  he  choked  his  wife  nearly  to  death  because  she  refused  to 
drink  out  of  an  old  skull  which  he  possessed. 

The  next  case  was  that  of  a  patient  to  whose  mental  alienation 
I  testified  most  emphatically.  He  grew  very  angry  with  me,  and 
even  threatened  to  horsewhip  me.  He  took  exceptions  to  the  fact 
tliat  the  court  had  appointed  an  attorney  to  defend  him,  stating 
that  he  was  fully  able  to  protect  himself, — that  he  entertained  the 
most  supreme  contempt  for  lawyers ;  and  at  the  commencement  of 
the  trial  he  ignominiously  dismissed  his  counsel.  He  conducted 
his  own  case  quite  energetically  and  skilfully,  examining  the  wit- 
nesses with  deliberation  and  care,  seizing  the  weak  points  in  their 
answers,  evincing  great  shrewdness  and  acumen.  The  jury  were 
evidently  staggered  by  his  brilliancy,  until  one  or  two  preposter- 
ous assertions  into  which  he  was  betrayed  convinced  every  one 
that  his  insanity  was  indubitable.  He  eventually  died  of  general 
paresis. 

Such  cases  actually  occur ;  and  these  Illustrations  are  not  in  the 
least  overdrawn.  You  will  often  have  very  cunning  insane  people 
to  deal  with.  I  remember  an  old  judge  who  was  at  St.  Vin- 
cent's Asylum,  and  who  was  a  monomaniac  on  the  subject  of  per- 
petual motion,  though  apparently  sane  on  every  other  subject.  He 
always  appeared  to  be  very  intelligent,  and,  after  a  long  stay  in 
the  asylum,  I  felt  convinced  that  he  should  be  discharged.  I 
therefore  determined  to  let  him  go ;  and  the  judge,  exceedingly 


INSANITY.  191 

thankful  and  grateful,  returned  borne.  Within  a  week,  he  became 
so  violent  that  he  was  sent  to  another  asylum ;  and  yet  I  made 
this  mistake  after  having  had  him  a  long  time  under  my  imme- 
diate observation.  So  you  see  that  an  insane  man  can  successfully 
conceal  his  derangement,  and,  eluding  your  vigilance,  perpetrate 
a  deed  of  violence.  His  conversation  may  show  no  symptoms  of 
the  mental  affection,  which  will  sooner  or  later  declare  itself.  If 
these  sources  of  error  exist,  is  there  any  particular  rule  by  which 
we  can  clearly  ascertain  the  existence  of  insanity  ?  Unfortu- 
nately, there  is  not ;  but  there  are  certain  important  considera- 
tions which  have  always  been  of  great  assistance  to  me  in  the 
diagnosis  of  difficult  cases,  and  which  I  shall  particularly  develop 
in  my  lecture  on  "Emotional  Insanity." 

It  is  strange  to  what  an  extent  the  popular  conception  of  insan- 
ity is  at  variance  with  fact.  In  the  popular  estimation,  unless 
wild,  incoherent,  violent,  or  boisterous,  one  is  not  insane. 

To  Folsom,  of  Boston,  a  recent  author  of  excellent  articles  on 
"  Mental  Diseases,"  published  in  Pepper's  "  American  System  of 
Medicine,"  I  am  indebted  for  much  that  is  pertinent  to  this  lecture. 
Commenting  upon  this  subject,  he  observes  that,  "  if  maniacal,  the 
timid  or  frightened  young  girl  who  would  not  hurt  a  fly,  and  the 
tottering,  harmless  old  man,  if  confused  and  partly  demented,  are 
hurried  off  to  the  asylum  with  the  use  and  show  of  force  suitable 
for  a  desperate  criminal ;  while  the  victim  of  overwhelming  delu- 
sions, because  he  seems  clear,  logical,  and  collected,  is  vigorously 
defended  against  the  physician's  imputation  of  insanity  until  he 
commits  an  offence  against  the  laws,  when  he  is  fortunate  if  he  is 
not  treated  as  a  criminal.  It  is  often  impossible  for  judges,  juries, 
counsel,  and  even  medical  experts,  to  wholly  divest  themselves  of 
the  popular  notions  of  insanity  in  cases  appealing  strongly  to  the 
passion  or  prejudice  of  the  day.  Cases  involving  the  question  of 
responsibihty  for  crime  are  decided  against  science  and  the  evi- 
dence, because  of  certain  preconceived  notions  upon  insanity  which 
no  amount  of  skilled  opinion  can  controvert.  Jurors,  and  less 
often  judges,  make  up  their  minds  what  a  sane  man  would  do 
under  given  conditions,  and  of  what  an  insane  man  is  capable, 
judging  from  the  facts  within  their  own  experience  ;  and  in  form- 
ing their  decisions  it  is  the  act  itself,  and  not  the  man,  diseased  or 
otherwise,  in  connection  with  the  act,  that  chiefly  governs  them. 


192  DISEASES   OF  THE  NEEVOUS  SYSTEM. 

Often  they  are  right,  not  seldom  wrong.  Strange,  apparently 
purposeless,  illogical,  inconsistent  action  is  frequently  attributed 
to  the  author  of  it  being  insane  on  that  subject,  whereas  he  may 
be  simply  acting  from  strong  impulse  or  emotion,  and  may  be  by 
no  means  insane.  On  the  other  hand,  because  a  man  knows  right 
from  wrong  in  the  abstract,  and  can  ordinarily  behave  well,  the 
very  characteristic  workings  of  his  insane  mind  are  often  seized 
upon  as  unquestionable  proof  of  sanity,  even  when  they  admit  of 
no  other  explanation  to  the  skilled  physician  than  that  of  insanity." 

The  above-cited  author  thinks  that  the  whipping  of  the  insane 
several  centuries  ago  put  an  end  to  much  insane  conduct,  and 
that  in  insane  asylums  of  the  present  day,  in  spite  of  the  best 
efforts  of  the  medical  staff  to  the  conti'ary,  a  brutal,  bullying 
patient  is  sometimes  struck  by  another  patient  or  an  attendant  in 
return  for  some  unusually  exasperating  and  cruel  conduct,  with 
the  result  of  making  him  behave  well  in  future.  "  It  is  with 
reference  to  this  class  of  cases  that  the  crowd  oftenest  errs  in  its 
definition  of  insanity.  Society  claims  a  voice  in  the  enforcement 
of  laws  for  its  own  protection,  assuming  to  know  who  could  con- 
trol themselves  from  crime  and  who  not,  and  naturally  wishes 
the  standard  of  responsibility  to  be  kept  high.  Of  course  its 
sympathies  and  prejudices  largely  govern  its  voice  in  the  matter." 

The  legal  conception  of  insanity  is  a  condition  of  mind  with 
reference  to  certain  conduct.  "  An  insane  man  is  simply  non 
compos  mentis.  Insanity  is  irresponsibility."  A  lawyer's  idea  of 
insanity  is  narroAver  than  that  of  the  physician,  regarding  it,  as 
he  does,  with  reference  to  a  certain  act  or  series  of  acts.  Folsom 
holds  that  in  wills  and  contracts  the  course  is  usually  clearer  than 
where  there  is  a  question  of  serious  crime,  and  that  "  even  an  insane 
person  in  an  asylum  may  be  a  party  to  a  valid  contract"  *  or  make 
a  will  that  will  hold  in  law.  In  this  opinion  he  is  in  accord  with 
some  of  the  highest  authorities,  especially  with  Kay  in  his  "  Medical 
Jurisprudence  of  Insanity."  It  is  undoubtedly  true,  as  the  former 
authority  holds,  that  a  will  should  fairly  represent  the  wishes  and 
character  of  the  man  making  it,  miinfluenced  by  insane  delusion 
or  prejudice,  and  that  it  should  bear  evidence  of  a  correct  appre- 
ciation of  the  circumstances  and  conditions  of  the  case,  and  of  a 

*  Italics  my  own. 


INSANITY.  1 93 

mind  acting  independently,  with  a  reasonable  knowledge  of  the 
duties  involved  and  of  the  just  rights  of  others. 

"  A  man  is  not  insane  in  law  unless  his  act  is  traceable  to,  or  its 
nature  lias  been  determined  by,  mental  disease  aiFecting  his  free 
agency  ;  in  other  words,  unless  insanity  caused  his  act  either  wholly 
or  in  great  part."     (Folsom.) 

The  facts  should  be  borne  in  mind  that  a  very  little  mental 
disease  can  make  bad  people  criminals  and  may  not  take  others 
beyond  the  bounds  of  propriety.  A  criminal  may  become  insane 
and  be  still  pretty  much  the  same  kind  of  a  criminal  as  before. 

The  question  of  responsibility  is  one  of  the  most  intricate  prob- 
lems which  the  physician  has  to  determine.  If  in  such  instances 
the  problem  were  limited  to  distinctive  and  well-admitted  forms 
of  insanity,  no  such  difficulty  would  exist ;  but  everybody  knows 
that  only  too  often  the  cases,  instead  of  being  comparatively  simple, 
are  of  a  most  perplexing  character.  It  should  never  be  forgotten 
that  the  insane  man  is  just  as  liable  to  commit  crime  as  an  ordinary 
criminal,  surrounded  as  he  is  but  too  frequently  by  the  same  con- 
ditions and  influences,  and  incited  by  the  ordinary  motives  of 
human  action.  A  man  does  not  cease  to  be  human  because  he 
becomes  insane.  Insanity  and  humanity  are  not  inseparable 
nor  incompatible.  The  propensities,  motives,  schemes,  peculi- 
arities, eccentricities,  dispositions,  moods,  and  general  character- 
istics of  sanity  frequently  coexist  with  insanity.  The  insane  as 
often  commit  certain  crimes  as  the  sane.  Truly  we  may  here 
maintain,  Avith  Folsom,  that  "  the  evidence  is  contradictory,  the 
testimony  as  to  previous  life  and  character  conflicting,  and  the 
disease  of  so  obscure  a  stage  or  type  that  it  is  almost  impossible 
to  form  a  clear  opinion.  The  determination  of  a  man's  degree  of 
free  agency  is  no  simple  affair  which  can  be  decided  in  all  cases 
by  a  few  or  a  dozen  interviews.  Not  seldom  the  mystery  remains 
unsolved  after  the  autopsy.  Man's  free  will  is  not  the  property 
of  any  substance  which  can  be  demonstrated  by  chemistry,  phys- 
iology, or  microscopical  research,  but  it  is  the  result  of  the  com- 
bined action  of  a  whole  group  of  functional  activities,  the  very 
relations  of  which  to  each  other  are  as  unknown  as  their  method 
of  action.  No  stethoscope  or  ophthalmoscope  can  rev.eal  its 
morbid  action,  which  can  only  be  inferred  indirectly  from  the 
operations  of  the  mind." 

13 


194  DISEASES   OF   THE   NERVOUS  SYSTEM. 

The  duty  of  the  physician  in  cases  of  insanity  is, — first,  to 
obtain  legal  control  of  an  individual's  actions,  as,  for,  instance,  by 
the  appointment  of  a  guardian, — viz.,  to  institute  a  de  lunatico 
inquirendo;  secondly,  to  deprive  the  patient  of  his  liberty  and 
place  him  in  an  asylum  ;  thirdly,  to  determine  his  criminality 
from  a  medico-legal  point  of  view,  or  to  estimate  his  capacity  to 
make  a  will  or  contract  or  to  transact  business. 

It  is  quite  important,  therefore,  as  Folsom  continues,  "  that  the 
medical  man  should  understand  that  there  may  be,  as  regards  some 
particular  person,  a  wide  difference  between  medical  insanity,  or 
mental  disease,  and  legal  insanity,  or  irresponsibility.  He  does 
most  wisely  when  he  confines  his  testimony  to  an  explanation 
of  the  changes  caused  by  disease  in  the  particular  case,  and  to 
the  effect  of  such  changes  upon  the  mind,  leaving  to  the  judge's 
charge  and  the  jury's  verdict  the  questions  of  guilt  and  responsi- 
bility." 

This  is  excellent  advice,  and  we  fully  agree  with  Folsom  that 
this  can  be  the  only  prerogative  of  a  medical  expert,  and  it  is  most 
unwise  for  him  to  encroach  upon  the  domain  of  judge  and  jury, 
and  pass  upon  questions  of  guilt  and  responsibility,  which  are 
entirely  outside  of  the  province  of  a  scientific  medical  witness. 
No  medical  expert  should  ever  prostitute  his  calling  by  having 
any  interest,  financial  or  otherwise,  involved  in  the  questions  at 
issue ;  nor  should  he  be  in  any  respect  biassed  in  his  opinions, 
either  before,  during,  or  after  the  trial. 

Science  is  truth,  and  the  medical  expert  upon  the  witness-stand 
is  there  placed  "  to  tell  the  truth,  the  whole  truth,  and  nothing  but 
the  truth." 

It  is  true  that  "  the  laborer  is  worthy  of  his  hire ;"  but  a  physi- 
cian should  not  accept  either  a  contingent  fee,  or  one  which  has 
any  relationship  to  the  interests  of  either  side  of  the  case.  His 
position  is  a  false  one  if  he  places  himself  in  the  attitude  of  an 
advocate,  as  he  is  interested  solely  in  supporting  and  explaining 
the  unvarnished  facts,  as  they  are  presented  to  his  investigation 
and  analysis  by  those  whose  duty  it  is  to  arrange  them  in  their 
correct  order  and  relationship. 

In  estimating  change  of  character,  the  individual  is  to  be  strictly 
compared  with  himself  at  some  previous  time,  and  not  with  some 
ideal  standard  of  mental  health  which  never  existed.     Truly,  as 


INSANITY.  195 

Folsom  observes,  "  if  we  could  measure  nicely,  no  two  of  us  could 
be  fairly  held  to  the  same  degree  of  accountability." 

The  questions  of  the  knowledge  of  the  distinctions  between 
right  and  wrong ^  and  of  the  presence  or  absence  of  delusions,  as 
bearing  upon  the  general  diagnosis  of  insanity,  will  be  fully 
discussed  in  our  lecture  upon  "  Emotional  Insanity." 

Folsom  is  well  sustained  in  his  opinion  by  authorities  when  he 
asserts  that  "  the  degree  to  which  the  individual  deviates  from  the 
path  of  the  law  may  depend  more  upon  his  training  and  surround- 
ings than  upon  his  disease, — points  which  must  always  be  considered 
in  establishing  a  definition  of  insanity  in  obscure  cases.  Of  two 
persons  whose  circumstances  in  life,  in  connection  with  a  certain 
amount  of  disease,  have  produced  as  nearly  as  possible  identical 
morbid  states,  it  now  and  then  happens  that  the  necessary  sur- 
roundings of  the  one  steady  and  support  him,  while  the  associa- 
tions and  conditions  of  life  throw  the  other  still  more  off  his 
balance.  The  one  is  able  to  sustain  the  ordinary  relations  with 
the  world ;  the  other  is  not." 

The  prevention  of  insanity  is  one  of  the  most  important  duties 
of  the  physician  ;  when  this  is  impossible,  its  early  and  energetic 
treatment  should  engage  his  prompt  and  unswerving  attention. 

This  fact  will  be  all  the  more  appreciated  when  it  is  recollected 
how  favorable  is  the  prognosis  and  how  successful  the  treatment 
of  this  dread  malady  in  its  earlier  stages.  Again  we  agree  with 
Folsom,  who  emphatically  states  that  it  is  not  the  doctor's  province 
to  punish  for  crime,  but  to  treat  for  disease,  and  that  the  doctor 
often  fails  to  appreciate  this  distinction. 

Medical  definitions  of  insanity,  remarks  Folsom,  in  text-books 
and  on  the  witness-stand,  do  not  clearly  enough  state  how  far  the 
medical  and  how  far  the  forensic  meaning  of  the  word  "  insanity" 
are  implied.  What  seem  to  be  wide  differences  of  opinion  regard- 
ing responsibility  for  crime,  as  given  in  the  courts,  are  often  due 
to  different  ways  of  stating  the  question,  and  nothing  more. 

Again  he  observes,  "  It  is  impossible  to  give  a  satisfactory  defi- 
nition of  insanity,  to  draw  any  hard  and  fast  line  on  one  side  of 
which  we  should  put  all  the  sane  and  on  the  other  all  the  insane. 
It  is  not  possible  to  divide  insanity  from  sanity  by  a  single  cri- 
terion." 

Boileau  said  that  all  men  are  insane,  the  only  difference  between 


196  DISEASES   OF  THE  NEEVOUS   SYSTE:\I. 

them  being  the  varying  degrees  of  skill  with  which  they  are  able 
to  conceal  the  crack. 

Montesquieu  observes  that  insane  asylums  are  built  in  order 
that  the  outside  world  may  believe  itself  sane. 

In  1832,  Haslam,  one  of  the  first  experts  in  mental  diseases  in 
England  at  that  time,  testified  in  court  that  he  had  never  seen  a 
sane  man  in  his  whole  life,  adding,  "  I  presume  the  Deity  is  of 
soimd  mind,  and  He  alone." 

Savage,  in  a  recent  excellent  treatise  on  "  Insanity  and  Allied 
Xem-oses,"  remarks,  "  The  first  question  naturally  is,  What  is 
meant  by  insanity  ?  I  shall  try  to  show  clearly  throughout  this 
work  that  no  standard  of  insanity,  as  fixed  by  nature,  can,  under 
any  circumstances,  be  considered  definitely  to  exist.  '  Sanity^  and 
'  insanity,'  as  recognized  by  the  doctor,  and  in  fact  by  the  general 
public,  must  be  but  terms  of  convenience.  No  person  is  perfectly 
sane  in  all  his  mental  faculties,  any  more  than  he  is  perfectly 
healthy  in  body." 

With  due  respect  to  these  eminent  authorities,  I  may  briefly 
qualify  such  opinions  as  needlessly  hyperbolical  and  unpractical. 

Spitzka  more  nearly  approaches  the  truth  in  this  connection 
when  he  says,  "  It  may  be  safely  asserted  that,  in  the  present  state 
of  our  knowledge,  it  is  impossible  to  frame  a  definition  of  insanity 
which,  while  it  meets  the  practical  every-day  requirements,  is  con- 
structed on  scientifLG  principles.  The  failure  of  the  best  authorities 
to  furnish  such  a  one  proves  that,  until  the  material  elements  of 
mental  derangement  become  more  accessible  to  observation  than 
they  now  are,  scientific  definitions  must  in  large  part  rest  on 
hypotheses.  The  practical  need,  however,  is  for  a  definition  which 
shall  include  neither  ambiguous  nor  theoretical  terms.  That  the 
brain  is  the  organ  of  the  mind  is  an  axiom  of  physiology ;  that 
insanity  is  a  manifestation  of  brain-disorder  is  a  resulting  dogma  of 
medical  psychology  ;  but,  even  if  we  could  establish  the  existence 
of  a  brain-lesion  in  every  case  of  brain-disturbance,  we  would  not 
be  able  to  formulate  the  topographical  and  patho-histological  con- 
ditions which  determine  the  falling  of  its  manifestations  within 
the  boundaries  of  insanity  in  one  case  and  without  them  in  another. 
And  neither  the  axioms  of  physiology  nor  the  dogmas  of  medical 
psychology  are  regarded  with  sufficient  respect  in  our  courts  of 
law — where  the  problem  of  an  accurate  definition  of  insanity  is 


INSANITY.  197 

apt  to  be  most  emphatically  presented  to  the  medical  mind — to 
render  their  use  in  filling  this  gap  in  our  knowledge  either  satis- 
factory or  profitable." 

In  a  foot-note,  Spitzka  adds  that  "  it  is  significant,  in  this  con- 
nection, that  none  of  the  most  recent  German  writers  on  insanity 
attempt  to  give  a  definition  of  insanity." 

Again,  with  Blandford,  speaking  of  insanity,  we  may  ask,  "  Can 
we  even  define  it  ?" 

"  To  define  true  madness,  what  is  it  but  to  be  nothing  else  but 
mad  ?" 

In  truth,  its  inscrutable  appearance  without  assignable  cause 
in  a  man  hitherto  sane,  and  its  no  less  inscrutable  departure,  are 
things  which  we  must  confess  are  not  yet  explicable  by  human 
knowledge. 

With  Clouston,  we  emphatically  assert  that  "  the  whole  conduct 
of  things  in  the  world  is  necessarily  so  based  on  the  assumption 
that  every  man  is  a  responsible  being,  with  a  sound  mind,  that 
any  exception  to  this,  when  it  occurs,  has  a  very  startling  effect." 

Baillarger  comes  very  near  the  whole  truth  when  he  states  that 
"  the  essential  element  of  insanity  is  loss  of  free  will.''  * 

Ball,  of  Paris,  describes  "  an  insane  man  as  one  who,  in  conse- 
quence of  a  profound  disturbance  of  the  intellectual  faculties,  has 
lost  more  or  less  completely  his  free  will  (liberie  morale),  and  has 
ceased  thereby  to  be  responsible  to  society  for  his  actions." 

Krafft-Ebing  says  that  "  it  is  a  logical,  self-evident  proposition 
that  the  organ  whose  function  under  normal  condition  is  to  bring 
about  all  mental  processes,  must  be  the  seat  of  changes  when  these 
functions  are  disturbed  ;"  and  Schiile  adds  that  "  the  study  of  dis- 
turbances of  the  mind  involves  the  changes  of  normal  mental 
functions  produced  by  disease.  .  .  .  Mental  diseases  are  brain- 
diseases,  but  they  are  more  than  that." 

Lord  Bramwell  once  said  that  "  insanity  is  strong  but  not  con- 
clusive evidence  of  innocence ;"  and  Lord  Blackburn  has  stated 
that  "  the  jury  must  decide  in  each  individual  case  whether  the 
disease  of  the  mind  or  the  criminal  will  was  the  cause  of  crime." 

Maudsley,  in  his  classic  work  on  "  Body  and  Mind,"  remarks, 
"  On  all  hands  it  is  admitted  that  the  manifestations  of  mind  take 

*  Italics  my  own. 


198  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

place  through  the  nervous  system,  and  that  its  derangements  are 
the  result  of  nervous  diseases,  amenable  to  the  same  method  of 
investigation  as  other  nervous  diseases.  Insanity  has  accordingly 
become  a  strictly  medical  study,  and  its  treatment  a  branch  of 
medical  practice.  Still,  it  is  also  too  true  that,  notwithstanding 
we  know  much  and  are  day  by  day  learning  more  of  the  physiol- 
ogy of  the  nervous  system,  we  are  only  on  the  threshold  of  the 
study  of  it  as  an  instrument  subserving  mental  function.  We 
know  little  more  positively  than  that  it  has  such  function ;  we 
know  nothing  whatever  of  the  physics  and  of  the  chemistry  of 
thought." 


LECTURE  XIII. 

INSANITY — continued. 

Classifications — Maudsley's  Classification — Etiology — Predisposing  Causes  :  Climate,  Re- 
ligion, Civilization,  Sex,  Period  of  Life,  Deficient  Education,  Individual  Predisposi- 
tion, Insane  Temperament — "  Border-Land  of  Insanity" — Exciting  Causes :  Mastur- 
bation, Drunkenness,  Epilepsy,  Transmutation  of  Nervous  Diseases,  Chronic  Diseases, 
Disorders  of  the  Sexual  Functions,  Injuries  to  the  Head — Moral  Causes. 

Gentlemen, — In  my  last  lecture,  when  speaking  of  insanity, 
I  referred  to  important  facts  regarding  its  character  and  definition. 
It  now  remains  for  me  to  classify  this  disease  in  accordance  with 
the  views  of  the  best  authorities.  It  is  quite  as  difficult  a  matter 
to  classify  insanity  as  to  define  it,  and  there  are  instances  where  it 
is  impracticable  to  arrange  some  of  its  manifestations  typically. 

I  am  a  believer  in  the  simplest  possible  division  of  the  different 
varieties  of  this  disease,  in  order  not  to  overburden  the  mind,  and 
am  convinced  that  Pinel's  method  is  most  satisfactory,  being  as 
follows:  1st,  Mania;  2d,  3Ielancholia ;  od,  Dementia;  4th,  Im- 
becility and  Idiocy.  (The  last  two  affections  are  considered  jointly 
simply  for  practical  purposes.)  Authors  have  studied  the  subject 
under  almost  numberless  classifications.  Dr.  Skae  has  originated 
a  very  elaborate  system,  whose  probable  advantage  consists  in  the 
arrangement  of  the  different  types  according  to  their  etiology. 

Van  der  Kolk,  of  Utrecht,  to  whom  medical  science  owes  a 
great  debt,  retains  two  principal  forms:  1st,  Idiopathic  insanity, 
arising  without  any  appreciable  cause,  primary  in  character,  and 
originating  exclusively  in  the  brain.  (In  my  last  lecture  I  ex- 
plained that  insanity  is  always  located  in  the  brain,  though  some- 
times its  origin  may  be  from  sources  altogether  foreign  to  that 
organ.)  2d,  Sympathetic  insanity,  which  includes  all  forms  pro- 
ceeding from  different  portions  of  the  human  economy,  as,  for 
instance,  the  viscera  of  the  thorax,  or,  more  frequently,  of  the 
abdomen  or  the  pelvis. 

199 


200  DISEASES   OF   THE   NERVOUS  SYSTEM. 

You  will  thus  perceive  that  the  origin  of  sympathetic  insanity 
may  be  sought  for  in  the  heart  and  lungs,  in  the  liver,  spleen, 
small  intestines,  colon,  etc.  Insanity  is  indeed  quite  often  sympa- 
thetic with  a  diseased  colon, — especially  where  melancholia  exists, — 
the  starting-point  not  infrequently  being  in  some  portion  of  the  ali- 
mentary canal.  Again, — as  all  practitioners  veiy  well  know, — 
certain  diseases  of  the  genito-urinary  apparatus  not  rarely  produce 
the  most  obstinate  forms  of  mental  aberration.  It  is  not  difficult 
to  understand  why  diseases  of  these  organs  should  sometimes  have 
this  determination,  if  you  take  into  consideration  the  complete 
harmony  which  normally  exists  between  all  parts  of  the  body 
and  the  central  organ  of  the  nervous  system, — the  brain.  No 
matter  how  remote  their  situation,  many  organic  complications 
give  rise  to  mental  disturbances  by  the  reflex  irritation  excited 
first  in  their  nerve-fibres  and  then  propagated  to  the  central 
nervous  dgp6t. 

One  more  fact  in  connection  with  the  sympathetic  form  is,  that 
these  remote  causes,  though  primarily  exciting  only  simple  func- 
tional disturbances  of  the  brain,  will,  if  not  removed, — the  reflex 
irritation  persistently  continuing, — produce  organic  disease,  de- 
veloping an  incurable  form  of  insanity.  The  more  obstinate  the 
duration  and  the  more  violent  the  irritation,  the  greater  is  the 
danger  of  organic  changes  in  the  histological  elements  of  the 
brain, — the  resulting  insanity  becoming  irremediable. 

The  classification  I  have  adopted  is  that  of  Maudsley,  and  is 
as  follows : 

"  If  a  broad  division  were  made  of  insanity  into  two  classes, 
— namely,  insanity  without  positive  delusion  and  insanity  with 
delusion, — in  other  words,  into  affective  insanity  and  ideational 
insanity ;  and  if  the  subdivisions  of  these  into  varieties  were  sub- 
sequently made, — would  not  the  classification,  general  as  it  may 
appear,  and  provisional  as  it  should  be  deemed,  be  really  more 
scientific  than  one  which,  by  postulating  an  exactness  that  does 
not  exist,  is  a  positive  hinderance  to  an  advance  in  knowledge  ? 
One  desirable  result  of  great  practical  consequence  could  not  fail 
to  follow, — that  is,  the  adequate  recognition  of  those  serious  forms 
of  mental  derangement  in  which  there  are  no  delusions.  I  have 
ventured  accordingly  in  a  former  publication  to  put  forward  the 
foUowinsi;  classification : 


INSANITY.  201 


"I.  Affective  or  Pathetic  iNSANriY. 

1.  Ilaniacal  perversion  of  the  affective  life.     Mania  sine  de- 
lirio. 

2.  Ilelancholio  depression  ivithout  delusion.     Simple  melancholia. 

3.  3£oral  alienation  proper.     Approaching  this,  but  not  reaching 
the  degree  of  positive  insanity,  is  the  insaiie  temperament. 

"II.  Ideational  Insanity. 

1.  General. 

a.  Mania.  [  Acute  and 

6.  Melancholia.  \    chronic. 

2.  Partial. 

a.  Monomania. 

b.  Melancholia. 

3.  Dementia,  primary  and  secondary. 

4.  General  paralysis. 

5.  Idiocy,  including  imbecility." 

The  next  time  we  meet  I  shall  give  a  short  description  of 
these  forms.  Contenting  ourselves  for  the  present  with  this  brief 
reference  to  the  classification  adopted,  we  next  shall  consider  the 
"  border-land  of  insanity." 

A  few  words  concerning  this  "border-land."  It  is  of  great 
importance  to  admit  the  existence  of  a  border-land  between  sanity 
and  insanity,  and  to  investigate  carefully  the  peculiarities  of  the 
cases  that  exist  therein. 

Maudsley,  in  commenting  upon  this  subject,  remarks,  "  Assu- 
redly it  is  a  fact  of  experience  that  there  are  many  persons 
who,  without  being  insane,  exhibit  peculiarities  of  thought,  feel- 
ing, and  character  which  render  them  unlike  ordinary  beings  and 
make  them  objects  of  remark  among  their  fellows.  They  may 
or  may  not  become  actually  insane,  but  they  spring  from  fami- 
lies in  which  insanity  or  other  nervous  disease  exists,  and  they 
bear  in  their  temperament  the  marks  of  their  peculiar  heritage. 
They  have,  in  fact,  a  distinct  neurotic  temperament,  a  certain  new- 
rosis,  and  some  of  them  a  more  specially  insane  temperament,  an 
insane  neurosis." 


202  DISEASES   OF  THE   KERVOUS   SYSTEM. 

In  treating  of  the  connection  }3etween  crime  and  insanit}^,  the 
same  writer,  in  his  work  on  "  Responsibility  in  Mental  Diseases," 
speaks  as  follows  :  "  If  the  secrets  of  their  natures  were  laid  open, 
how  many  perverse  and  wrong-headed  persons,  whose  lives  have 
been  a  calamity  to  themselves  and  others,  how  many  of  the  de- 
praved characters  in  history,  whose  careers  have  been  a  cruel 
chastisement  to  mankind,  would  be  found  to  have  owed  their  fates 
to  some  morbid  predisposition  !" 

Eegarding  the  influence  of  physical  effects  upon  temperament 
and  moral  well-being.  Dr.  Wigan  observed,  "I  firmly  believe 
that  I  have  more  than  once  changed  the  moral  character  of  a  boy 
by  leeches  to  the  inside  of  the  nose," 

Dr.  Savage,  in  his  work  on  insanity,  says,  "  There  can  be  no 
doubt  in  the  minds  of  those  who  see  much  of  the  criminal  classes 
and  of  those  who  see  much  of  the  insane  classes,  that  there  is 
something  in  common  between  them.  I  must  not  be  misunder- 
stood in  saying  this,  for  there  is  an  immense  difference  between 
some  insane  persons  and  some  criminals ;  but,  as  the  savage  and 
the  statesman  have  connecting  links  between  them,  so  among 
criminals  and  lunatics  there  are  many  grades  which  approach  one 
another  very  closely.  To  begin  with,  the  physical  aspect  of  a 
chronic  lunatic  resembles  very  closely  that  of  a  confirmed  crimi- 
nal, and  the  mental  degeneration  of  man  leaves  his  features  so 
changed  and  debased  that  he  resembles  the  man  who,  from  vice 
of  birth  or  faulty  surroundings,  has  never  developed  the  higher 
social  qualities.  As  Dr.  Maudsley  has  well  pointed  out, '  Though 
there  is  a  border-land,  there  is  no  boundary-stone ;  and  there  are 
cases  in  which  exist  some  insanity  and  much  crime,  and  others 
with  much  insanity  and  little  crime.'  And  at  present  this  border- 
land is  the  one  on  which  most  forensic  battles  have  to  be  fouirht. 
Though  from  theoretical  points  of  view  it  may  appear  that  any 
one  with  criminal  tendencies  must  be  looked  upon  as  insane  (as 
one,  in  fact,  who  cannot  be  calculated  upon,  and  whose  actions  are 
not  governed  and  controlled  as  are  those  of  the  ordinary  social 
unit),  yet  society,  as  represented  by  lawyer,  judge,  and  jury,  will 
continue  to  hold  the  balance  in  its  own  hands,  and  punish  those 
who  may,  after  all,  be  of  unsound  mind,  the  expert's  opinion 
notwithstanding." 


KSrSANITY.  203 


ETIOLOGY   OF   INSANITY. 


Insanity  is  not,  as  was  formerly  supposed,  a  mere  hypothetical 
disease, — an  imaginary  or  metaphysical  affection  of  the  mind. 
The  mind,  being  intangible  and  immaterial,  cannot  be  subjected 
to  disease.  Insanity  is  a  disorder  of  the  brain,  just  as  pneumonitis 
is  an  inflammation  of  the  lungs,  pleuritis  an  inflammation  of  the 
pleural  sac,  or  typhoid  fever  a  specific  blood-poisoning ;  and  the 
disordered  evolution  of  mental  phenomena  observed  during  the 
course  of  insanity  is  but  the  morbid  manifestation  of  a  brain 
which,  from  physical  causes  originating  in  disease,  is  unable  to 
perform  its  proper  physiological  functions. 

The  fact  that  insanity  is  a  disease  of  the  brain  is  one  of  the 
greatest  importance,  showing  us  the  gross  injustice  inflicted  in 
times  past  upon  individuals,  casting  upon  them,  as  it  did,  the 
stigma  of  social  ostracism.  It  was  supposed  that  they  were  suffer- 
ing from  some  uncommon  malady  wrought  by  mysterious  influ- 
ences, or  sent  as  a  punishment  from  the  gods.  Such  theories 
were  as  preposterous  as  they  were  unfortunate.  All  individuals 
are  more  or  less  liable  to  this  calamity.  But  why  are  some  people 
insane  and  others  not  ?  Why  does  insanity  not  affect  indiscrimi- 
nately all  the  members  of  a  family  ?  Why  does  it  show  a  predi- 
lection for  certain  persons,  selecting  its  victims  with  remarkable 
consistency?  We  have  already  adverted  to  the  laws  relating  to 
this  liability,  and  have  considered  it  as  founded  in  an  "  unstable 
condition  of  the  nervous  elements,^'  peculiarly  prone  to  perturbation 
of  their  equilibrium,  whereby  more  or  less  interference  with  all 
the  functions  connected  with  the  development  of  mental  phenom- 
ena is  produced,  the  person  thus  suffering  ceasing  to  be  rational 
and  responsible.  Where  such  a  predisposition  exists  there  is  like- 
wise an  unstable  constitution  of  the  cells  connected  with  the  evo- 
lution of  the  moral  or  intellectual  faculties;  and  this  instability 
is  born  with  the  individual  and  inherent  in  him,  having  existed 
from  the  first  moment  of  his  life.  Let  us  suppose  two  individ- 
uals, one  of  whom  is  subjected  to  violent  mental  emotions,  or  to 
other  causes  eminently  calculated  to  lead  to  insanity.  Should  no 
predisposition  exist,  this  person  will  almost  certainly  pass  through 
the  ordeal  unscathed.  The  second  individual,  on  the  other  hand, 
possessing  the  liability,  on  being  exposed  to  precisely  the  same 


204  DISEASES   OF   THE   NERVOUS  SYSTEM. 

agencies,  will  most  probably  become  mad, — the  cortical  cells  now 
no  longer  performing  their  duty  normally. 

If  we  knew  all  the  causes  leading  to  insanity,  or  could  foresee 
contingencies  which  may  arise,  then  we  might  venture  to  predict 
insanity  in  certain  individuals  or  families  at  particular  periods  of 
their  lives.  However,  insanity  does  not  depend  upon  one,  or  a 
few,  but  upon  a  multiplicity  of  causes ;  and,  as  Maudsley  remarks, 
"  hereditary,  predisposing  moral  and  physical  causes  are  not  alone 
necessary,  but  a  combination,  a  concurrence  of  conditions,  and 
then  lunacy  follows." 

Let  us  now  review  some  of  the  leading  causes  of  insanity. 

1st.  Climate — which  seems  to  have  some  influence  in  the  pro- 
duction of  this  malady.  Indeed,  I  have  frequently  observed  that 
on  dark,  moist,  gloomy  days  the  majority  of  insane  persons  are 
worse :  the  melancholic  cases  are  more  deeply  depressed,  and  the 
maniacal  are  more  difficult  to  control.  There  seems  to  be  also  a 
peculiar  disposition  towards  a  cure  at  certain  periods  of  the  year, 
— in  spring  especially,  when  everything  in  nature  is  being  en- 
dowed with  renewed  life  and  vigor.  In  curable  patients  we  fre- 
quently find  the  disease  singularly  yielding  at  this  time  of  the 
year, — a  fact  mentioned  by  Esquirol.  Most  of  you  have  proba- 
bly experienced  a  peculiarly  depressing  eifect  upon  a  gloomy  day 
when  the  sky  is  overcast.  And  if  this  influence  be  felt  by  sane 
persons,  how  much  more  will  it  impress  the  insane,  or  those  in 
whom  an  hereditary  predisposition  exists  !  Should  this  influence 
be  unduly  continued  in  such  predisposed  persons,  insanity  may  be 
developed ;  a  fact  which  partly  explains  why  suicides  are  so 
frequently  committed  during  dull  and  dreary  weather. 

2d.  Religion,  it  is  held,  is  often  a  cause  of  insanity.  In  nervous 
temperaments  subjected  to  intense  religious  excitement,  as  revivals, 
for  instance,  danger  of  mental  disease  is  to  be  apprehended.  I 
have  witnessed  many  instances  of  this  kind,  disastrous  nervous 
complications  having  fanaticism  as  their  immediate  precursor. 
Indeed,  the  effects  of  the  mental  emotions,  reacting  upon  the 
physical  organism,  are  so  extraordinary,  owing  to  their  expansive 
character,  that  it  is  easy  enough  to  understand  how  they  may  be 
fruitful  sources  of  insanity.  Maudsley  aj^tly  remarks,  in  his 
work  on  "  Body  and  Mind,"  that  "  when  the  emotions  are  very 
much  disturbed  there  is  a  proportionate  disarrangement  in  the 


INSANITY.  205 

cortical  cells  presiding  over  the  moral  functions,  nervous  influence 
being  liberated  with  great  force  ;  this  is  transmitted  along  certain 
appropriate  nerves,  and  the  impulse  consequent  upon  the  original 
liberation  of  nerve-force  mav  be  so  great  as  to  produce  intense  and 
notable  effects  at  distant  points,  where  it  ig  received  and  ultimately 
distributed."  These  phenomena  may  be  compared  to  those  pro- 
duced by  a  powerful  galvanic  battery  generating  a  current  of 
great  tension  transmitted  along  conducting  wires,  a  violent  shock 
occurring  at  the  point  of  arrest ;  while  if  this  point  of  arresta- 
tion  furnish  a  resistance  corresponding  with  the  strength  of  the 
discharge,  destructive  and  disorganizing  effects  will  ensue.  This 
is  not  unlike  what  occurs  when  a  person  is  struck  by  lightning. 
Agitation  from  either  intense  grief  or  unbounded  joy  may  be  so 
excessive  as  to  produce  sudden  death.  Death  thus  occasioned  was 
formerly  commonly  supposed  to  be  the  result  of  a  broken  heart ; 
but  in  reality  it  is  simply  the  effect  of  the  overpowering  violence 
of  the  emotions  upon  the  nervous  centres,  and  not,  as  was  pre- 
viously imagined,  a  muscular  laceration. 

3d.  Another  predisposing  cause  is  said  to  be  civilization  and 
its  'progress.  It  is  time  tliat  among  savages  insanity  is  exceedingly 
rare.  In  what  way  does  civilization  tend  to  produce  insanity  ?  you 
ask.  Perhaps  by  the  expansive  wants  therefrom  arising,  often  to 
be  satisfied  only  at  the  expense  of  health, — all  the  powers  of  man's 
organization  being  brought  into  requisition  and  overtaxed  in  the 
daily  struggle  for  self-maintenance  and  individual  pre-eminence. 
In  many  instances  where  labor  is  chiefly  of  a  mental  character, 
there  is  but  too  often  an  excessive  strain  upon  the  intellectual 
faculties.  Should  this  happen  in  connection  with  hereditary  pre- 
disposition to  insanity,  it  is  probable  the  mind  will  succumb,  its 
possessor  being  thrown  back  among  the  crowded  ranks  of  the 
unsuccessful,  and  sunk  perhaps  into  hopeless  lunacy.  Indeed,  in 
the  professional  man,  whose  bread  is  usually  entirely  dependent 
upon  never-ceasing  brain-work,  the  retrograde  metamorphosis  of 
tissue  must  be  enormous ;  and  should  the  slightest  instability  in 
his  nervous  system  exist,  the  sum  of  his  efforts  may  eventually 
cause  a  disturbance  leading  to  the  development  of  insanity.  In 
this  way  may  civilization  be  productive  of  the  disease.  It  is 
estimated  that  in  civilized  communities  the  proportion  afl&icted  is 
about  one  in  five  hundred. 


206  DISEASES   OF   THE   XERVOUS   SYSTEM. 

4th.  Sex  undoubtedlj  exercises  some  effect ;  for  instance,  a  ner- 
vous, hvsterical  woman  is  much  more  liable  to  become  insane  than 
a  delicately-organized  man  exposed  to  the  same  influences.  In 
debilitated  women,  especially  in  moments  of  jov  or  grief,  you 
always  have  cause  to  dread  incidental  insanitj\  When  a  mother 
loses  her  darling  child,  the  emotional  disturbances  are  often  ter- 
rible, and  you  may  fear  the  result ;  but  these  apprehensions  natu- 
rally do  not  extend  to  the  father.  Indeed,  it  is  very  improbable 
that  a  man  could  be  constituted  with  such  a  delicate,  nervous,  and 
excitable  temperament  as  a  woman :  his  very  organization  pre- 
cludes this  idea  ;  and  it  is  doubtftd  if  he  be  capable  of  experiencing 
the  same  intensity'  and  exaltation  of  the  emotions  as  his  more  frail 
and  tender  partner. 

oth.  The  period  of  life,  also,  seems  to  possess  a  certain  degree 
of  influence  as  a  predisposing  cause  of  insanity'.  At  the  time  of 
puberty,  and  also  among  women  at  the  appearance  of  their  meno- 
pause, we  often  find  the  development  of  mental  complications. 
In  man,  even,  it  is  contended  that  an  equivalent  change  of  life 
occurs  at  a  certain  advanced  age,  though  not  always  accompanied 
by  a  loss  of  sexual  capacity,  the  sexual  proclivities  frequently 
seeming  to  be  enhanced,  as  a  prelude  to  approaching  decay.  At 
this  time,  in  consequence  of  the  activity  of  the  retrograde  processes, 
insanity  seems  niarkedly  to  increase. 

6th.  Education  is  the  next  cause  to  be  considered.  In  de- 
ficiently-educated children  (I  refer  principally  to  moral  education), 
whose  training  has  been  neglected,  whose  propensities  to  evil  have 
been  gratified  rather  than  checked,  whose  bad  temper  has  been 
developed  instead  of  restrained,  and  in  whom  any  instability  of 
the  nervous  element  exists,  the  least  exciting  cause  may  bring 
about  insanity.  It  is  a  mother's  care  and  training  wliich  make 
us  the  men  we  are  ;  and  we  can  never  sufficiently  appreciate  her 
tender  discipline  and  solicitude,  since  but  for  her  constant  and 
untiring  efforts  we  might  have  been  perverse,  if  not  insane.  On 
the  other  hand,  excessive  mental  strain,  such  as  is  sometimes 
required  in  the  school  education  of  our  youth,  may  be  equally 
pernicious. 

7th.  Individual  predisposition  is  a  cause  to  which  I  have  already 
adverted.  It  is  consequent  upon  hereditary  tendency,  or  it  may 
be  acquired.     ]\Iany  authors  state  that  at  least  fift}'  per  cent,  of 


INSANITY.  207 

the  cases  of  insanity  are  of  ancestral  transmission ;  and  I  am  in- 
clined to  the  belief  that  even  this  is  an  under-estimate.  It  is  also 
asserted  that  this  inheritance  is  more  apt  to  descend  from  the 
mother  than  from  the  father.  Children  are  in  much  greater 
danger  when  their  mother  has  been  insane  prior  to  their  birth 
than  when  the  disease  appears  at  a  subsequent  period.  In- 
sanity is  perhaps  more  readily  transmitted  to  daughters  than  to 
sons. 

8th.  The  insane  temperament  is  that  condition  in  which  "an 
individual  is,  by  reason  of  a  bad  descent,  born  with  a  predispo- 
sition to  insanity  ;  he  has  a  native  constitution  of  nervous  element 
which,  whatever  name  we  give  it,  is  unstable  and  defective,  ren- 
dering him  unequal  to  the  severe  stress  of  adverse  events.  In 
other  words,  the  man  has  the  insane  temperament ;  he  is  liable  to 
whimsical  caprices  of  thought  and  feeling  ;  and  although  he  may 
act  calmly  and  rationally  for  the  most  part,  yet  now  and  then  his 
unconscious  nature,  overpowering  and  surprising  him,  instigates 
eccentric  or  extravagant  actions;  while  an  extraordinary  and 
trying  emergency  may  upset  his  stability  entirely."  (Maudsley.) 
"  He  suffers  from  the  worst  of  all  tyrannies,  the  tyranny  of  a  bad 
organization."     (Sheppard.) 

This  mental  condition  is  most  important  in  its  medico-legal 
bearings ;  and  the  defence  of  Joseph  Fore — who  was  tried  for 
murder  in  the  first  degree  and  acquitted — was  conducted  success- 
fully upon  this  very  theory.  His  subsequent  actions  and  behavior 
and  sad  death  clearly  substantiated  the  fact  that  the  plea  was  well 
grounded  and  justly  maintained. 

The  exciting  causes  of  insanity  are  divided  into  physical  and 
moral. 

1st.  A  very  frequent  physical  cause  of  insanity  is  masturbation, 
a  disgusting  vice,  to  which,  I  must  say,  I  believe  an  astonishing 
number  of  lunatics,  either  as  a  cause  or  as  a  consequence  of  their 
disease,  are  victims, — many  more  than  the  statistics  of  asylums 
show,  owing  probably  to  the  false  delicacy  which  causes  patients 
and  their  friends  to  conceal  the  truth. 

2d.  Drunkenness  is  another  of  the  causes  of  insanity.  Men 
are  often  habitual  drunkards  before  they  realize  it ;  they  then  find 
it  more  difficult  to  dispense  with  liquor  than  with  their  meat  and 
bread.    Experience  leads  me  to  believe  that  inebriety  as  an  exciting 


208  DISEASED    OF    THE    ^"XET0^5    ST5TEAI. 

cause  constitutes  the  principal  factor  in  about  one-third,  if  not  in 
one-half,  of  the  whole  number  of  cases  of  insanity, 

3d.  Epilepsy  is  mentioned  as  a  cause  of  insanity  by  some 
authors,  while  others  contend  that  it  is  more  frequently  a  result 
thereof.     This  we  shall  attempt  to  decide  farther  on. 

4th,  Transmutation  of  nervous  diseases,  so  called  by  Trousseau, 
meaning  that  a  nervous  disease  in  one  generation  may  be  trans- 
mitted to  the  next  or  the  second  generation,  but  with  a  change  in 
form,  is  also  a  cause  of  insanity.  Hence  we  observe  chorea  in  the 
children  or  grandchildren  of  epileptics,  and  vice  versa,  these  dis- 
eases not  infrequently  resulting  in  insanity.  It  sometimes  happens 
that  the  transmission  of  nervous  disease  will  take  a  dilierent  form 
for  each  member  of  a  family, — ^neuralgia  in  one,  alcoholism  in 
another,  epilepsy  or  hysteria  in  a  third,  and  in  a  fourth,  insanity. 

5th.  That  chronic  diseases  are  remarkably  prt^ductive  causes  of 
insanity  is  not  an  astonishing  £ict  when  you  recall  what  I  have 
stated  as  r^ards  the  nece^ty  of  a  normal  state  of  the  blood  in 
order  to  insure  a  healthy  condition  of  the  ftmctions  of  the  nervous 
systenL  Consequently,  an  anaemic  or  a  hyperaemic  brain  is  inca- 
pacitated for  a  proper  performance  of  ideation.  The  same  residt 
would  happen  in  rheumatic  or  gouty  affections,  in  syphilis  and 
other  diseases  due  to  blood-poisoning,  whether  of  a  vegetable,  an 
animal,  or  a  mineral  character,  or  whether  the  result  of  dyscrasise 
or  of  acute  febrile  diseases.  Insanity,  however,  is  by  no  means 
an  inevitable  result  in  all  cases  of  this  nature, — the  absence  or 
presence  of  an  inherent  predisposition  playing  the  most  important 
part  in  its  superinduction.  There  is,  moreover,  as  I  have  told 
you,  a  certain  class  of  patients  who  do  not  remain  permanently 
insane,  but  after  an  attack  of  insanity  return  to  their  normal 
condition,  to  relapse  again,  making  it  very  difficult  to  anticipate 
their  future  status  with  any  certainty. 

'6th.  Derangefnent  of  the  sexual  functions  has  an  extraordinary 
relation  to  insanity.  In  females  especially  many  abnormal  con- 
ditions of  the  uterus,  such  as  retroversion,  prolapsus,  etc.,  are  active 
agents  in  this  respect.  In  curing  the  primary  affection  you  will 
cause  the  entire  disappearance  of  the  insanity. 

Van  der  Kolk  relates  a  c-ase  of  prolapsus,  attended,  by  melan- 
cholia, which  was  relieved  upon  the  reduction  of  the  prolapsus. 
But  on  removing  the  pessary  the  symptoms  of  melancholia  imme- 


INSANITY.  209 

diately  reappeared,  to  vanish  again  upon  renewed  reduction.  This 
statement  admits  of  no  doubt  whatever,  having  been  confirmed 
by  the  experience  of  numerous  other  alienists.  "  It  is  certain  that 
an  attack  of  mania  has  followed  the  suppression  of  the  menses, 
and  that  the  return  of  menstruation  is  often  followed  bv  recoverv 
from  insanity ;  but  it  is  certain  also  that  outbreaks  of  maniacal 
fury,  or  of  suicidal  or  of  homicidal  violence,  have  coincided  with 
the  period  of  menstruation.  .  .  .  Fleming  relates  two  cases  in 
which  melancholia  was  cured  by  the  use  of  a  pessary,  in  one  of 
them  regularly  returning  whenever  the  pessary  was  removed ;  and 
I  have  seen,  in  one  case,  severe  melancholia  of  two  years^  dura- 
tion disappear  after  the  cure  of  a  prolapsus  uteri.  Instances  are 
on  record  in  which  women  have  rea:ularly  become  insane  durincr 
each  pregnancy ;  and,  on  the  other  hand,  Guislain  and  Griesinger 
mention  a  case,  respectively,  in  which  insanity  disappeared  during 
pregnancy,  the  patient  at  that  time  only  being  rational."  (Mauds- 
ley.)  Some  of  these  women  become  insane  before  parturition, 
some  immediately  after,  and  others  during  lactation.  These  facts 
are  of  importance,  and,  whether  a  specialist  or  not,  the  physician 
cannot  afford  to  ignore  them,  as  their  significance  is  evident. 

7th.  Injury  to  the  head  is  often  the  cause  of  most  insidious, 
dangerous,  and  intractable  forms  of  insanity.  I  believe  that  all 
severe  blows  upon  the  head,  sooner  or  later,  may  cause  very 
serious  brain-symptoms,  though  years  may  elapse  before  their 
appearance.  In  such  cases,  if  you  carefully  analyze  their  history, 
it  will  be  e\"ident  that  the  insanity  was,  beyond  doubt,  directly 
caused  by  the  blow.  Forbes  Winslow  contends  that  these  disas- 
trous and  insidious  consequences  resulting  from  injuries  of  the 
head  are  too  often  overlooked.  I  have  witnessed  a  case  of  pachy- 
meningitis and  resulting  cerebral  abscess  from  extension  of  the 
morbid  process  by  contiguity  of  tissue,  the  effect  of  a  traumatic 
injury  of  the  cranial  vault  inflicted  twenty-three  years  previously. 
In  the  mean  time  the  individual  had  amassed  a  large  fortune  by 
industry  and  successful  financiering. 

The  moral  causes  of  insanity  consist  simply  in  undue  violence 
of  the  emotions,  which,  when  occurring  in  persons  possessing  an 
inherent  tendency  to  insanity,  very  seldom  fails  to  result  unfortu- 
nately. Among  the  more  dangerous  emotions  we  find  those  of 
anger,  jealousy,  hatred,  and  love  very  prominent.    Sudden  reverses 

14 


210  DISEASES   OF   THE   NEKVOUS   SYSTEM. 

of  fortune,  and  the  consequent  sensations,  have  often  caused  a 
dethronement  of  reason.  Not  only  a  change  from  wealth  to 
poverty,  but  the  reverse  also  may  result  in  mental  disease.  The 
excitements  incident  to  war,  and  its  disastrous  consequences, 
have  afforded  ample  illustrations  of  insanity  consequent  upon 
violence  of  the  emotions.  In  a  word,  whenever  the  mind  is 
subjected  to  undue  strain,  or  whenever  the  passions  are  extra- 
ordinarily roused,  other  conditions  being  favorable,  mental  aliena- 
tion may  ensue. 


LECTURE    XIY. 

EMOTIONAL   INSANITY,   AND   ITS   MEDICO-LEGAL   RELATIONS. 

Gentlemen, — Insanity  is  necessarily  a  disease  that  must  inter- 
est }"ou  all,  because  it  is  a  physical  affliction  which  sooner  or  later 
may  invade  the  sacred  precincts  of  your  own  homes.  It  is  a 
disease  which,  in  the  present  condition  of  society,  is  becoming 
extremely  rife,  keeping  pace,  some  authors  hold,  with  advancing 
civilization. 

A  certain  fascination  clings  to  the  study  of  mental  pathology. 
Clinical  observations  teach  us  that  the  wear  and  tear,  the  stress, 
the  contentions,  troubles,  competitions,  and  annoyances  of  every- 
day life,  engulf  many  minds,  so  constituted,  in  consequence  of 
inherent  weaknesses,  as  not  to  be  able  to  resist  such  inevitable 
influences.  In  other  words,  as  men  must  bear  the  strain  and 
friction  of  every-day  life,  insanity  correspondingly  increases. 

In  the  present  period  of  pathological  enlightenment,  the  fact 
that  insanity  is  a  disease  of  the  brain  should  admit  of  no  dispute. 
The  interest  of  its  study  will  be  enhanced  by  our  natural  efforts 
to  unravel  its  multitudinous  phenomena ;  and  in  seekifig  for  ex- 
planations of  its  complex  manifestations  we  are  often  compelled 
to  attempt  to  explore  the  labyrinths  and  mysteries  of  brain- 
action.  Of  the  latter,  it  is  true,  we  have  overmuch  to  learn ; 
nevertheless,  the  researches  of  modern  science  have  not  been 
entirely  fruitless,  but  have  been  productive  of  excellent,  if  not 
indeed  very  remarkable,  results. 

We  can  at  least,  in  consequence  of  this  progress  in  the  right 
direction,  dismiss  the  old  mythical  theories  of  the  metaphysicians, 
— obsolete  views,  never  again  to  be  rejuvenated, — which  taught 
people  to  believe  that  in  dealing  with  the  phenomena  of  insanity 
they  were  witnessing  or  combating  nonentities,  shadows,  spiritual 
processes,  mystical  conditions  of  still  obscurer  origin,  as  opposed 
to  the  purely  physical  symptoms,  the  outcroppings  or  manifesta- 

211 


212  DISEASES   OF   THE  NERVOUS   SYSTEM. 

tions  of  brain-lesions,  more  or  less  demonstrable  in  all  eases  when 
subjected  to  the  crucible  of  modern  investigation. 

Formerly  insanity  involved  social  ostracism,  and  the  prejudices 
which  its  supposed  stigma  originated  exist  with  curious  perti- 
nacity even  at  the  present  day,  notwithstanding  the  teachings  of 
science.  It  was  once  considered  necessary  that  the  victim  of  this 
disease  should  forever  be  sequestered  from  society,  and  his  mis- 
fortune involved  his  family  in  almost  equal  disgrace. 

We  know  now  that  insanity  is  simply  a  physical  aflQiction,  in- 
stead of  a  morbus  sacer,  and  the  result  of  certain  well-recognized 
pathological  deviations  ;  that  it  not  infrequently  originates  in  con- 
gestions and  inflammatory  conditions  of  the  brain ;  and  that,  just 
as  pneumonia  is  an  inflammation  of  the  lungs,  pleuritis  an  inflam- 
mation of  the  pleura,  and  nephritis  an  inflammation  of  the  kid- 
neys, so  is  insanity  a  departure  from  the  physiological  status  of 
the  brain  necessary  for  the  proper  evolution  of  healthy  mental 
and  emotional  phenomena,  having  its  starting-point  in  the  same 
vascular  and  irritative  disturbances  that  give  rise  to  other  patho- 
logical states. 

Van  der  Kolk  divided  insanity  into  idiopathic  and  sympathetic 
insanity.  The  former  originates  primarily  in  the  brain  proper, 
the  latter  is  but  the  reflex  radiation  of  remote  disturbances,  start- 
ing frequently  in  other  parts  of  the  human  organism,  and  propa- 
gated in  constant  irritative  waves  towards  the  central  organ  of  the 
nervous  systeifi.  Diseases  of  the  viscera,  whether  situated  in  the 
pelvic,  the  thoracic,  or  the  abdominal  cavity,  are  common  causes  of 
insanity,  which  in  such  instances  is  superinduced  by  the  reflection 
of  such  disturbances  upon  the  brain,  resulting  in  congestions  and 
inflammatory  conditions,  sooner  or  later  inducing  insane  manifes- 
tations. 

Such  a  result  is  not  astonishing  when  the  wonderful  sympathies 
of  the  brain  with  every  portion  of  the  human  economy  are  taken 
into  consideration.  The  intimate  relation  of  the  brain  with  every 
other  oro;an,  blendino;  various  interests  in  one  harmonious  whole 
for  the  common  weal,  is  an  indisputable  fact. 

This  is  still  less  diflicult  to  appreciate  when  it  is  recollected  that 
the  brain  is  the  supreme  centre  presiding  over  all  other  parts  of 
the  nervous  system  and  the  animal  economy.  Indeed,  we  can 
hardly  conceive  of  any  constituent  atom  of  the  body,  no  matter 


EMOTIONAL   INSANITY.  213 

where  found,  wliieli  is  not  in  more  or  less  intimate  relation  with 
the  brain.  Hence  may  it  well  be  said,  as  has  been  done  by  a 
certain  writer,  that  when  a  man  becomes  insane  he  is  insane  to 
the  veiy  tips  of  his  fingers. 

The  brain  may  truly  be  said  to  be  the  seat  of  the  regulative 
force  of  all  the  phenomena  of  the  mind,  of  the  emotions,  intel- 
lectual acts,  and  volitional  manifestations. 

The  term  "  insanity"  is  comprehensive  in  character.  When  we 
speak  of  insanity  in  general,  we  do  not  refer  to  one  particular 
form  of  the  disease,  but  we  include  in  the  term  a  very  great  va- 
riety of  morbid  brain-manifestations.  Just  as  the  word  "  tumor" 
has  frequently  the  most  varied  significance,  suggestive,  as  it  is,  of 
many  physical  varieties  and  characteristics,  numerous  classifica- 
tions, terminations,  and  pathological  origins,  so  the  word  "in- 
sanity" is  to  the  psychological  physician  a  mine  so  rich  and  varied 
in  its  productions,  so  deep,  intricate,  and  labyrinthic,  as  to  be  quite 
inexplorable  to  the  limit  we  desire.  You  can  therefore  form  some 
adequate  idea  of  the  comprehensiveness  of  this  term  "  insanity." 

Before  studying  emotional  insanity  in  particular,  let  us  con- 
sider some  other  points  connected  with  the  general  subject  of 
insanity. 

Is  there  anything  in  the  aspect  or  appearance  of  the  insane 
which  will  enable  us  invariably  to  recognize  the  existence  of  the 
disease  by  a  casual  observation  of  the  physiognomy  ?  A  fallacy 
of  very  common  occurrence  exists  in  this  connection. 

During  medico-legal  contests,  we  often  hear  allusions  by  the 
contesting  lawyers  to  the  "  wild  eye  of  the  insane,"  as  a  proof 
of  incontestable  alienation.  This  method  of  recognition  of  the 
disease  rests  upon  a  very  unscientific  basis. 

All  physicians  who  are  familiar  with  the  phenomena  of  insanity, 
and  are  accustomed  to  explore  "  the  mind  diseased,"  in  judging 
of  the  presence  or  absence  of  the  former,  know  full  well  the  dif- 
ficulty and  fallibility  of  conclusions  based  upon  such  premises. 

A  careful  study  and  analysis  of  the  physical  conditions  or  the 
symptomatic  manifestations  of  insanity  will  clearly  indicate  how 
little  can  be  determined  by  attention  to  the  countenance  alone. 
Let  any  person  who  doubts  this  assertion  visit  the  wards  of  a 
lunatic  asylum,  and,  after  a  purely  demented  patient  has  been 
observed  (whose  features  unmistakably  indicate  the  departure  of 


214  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

all  reason  and  expression),  let  him  watch  the  large  majority  of 
patients  who  remain,  engaged,  as  they  may  be,  in  billiards,  chess, 
the  perusal  of  periodicals,  and  the  enjoyment  of  cards,  and,  while 
giving  an  attentive  ear  to  their  conversation  and  studying  their 
features,  endeavor  to  determine  from  such  observation  alone 
whether  or  not  reason  be  dethroned.  His  task  would  be  one  of 
herculean  magnitude.  It  must  not  be  imagined  that  insanity  is 
an  affection  whose  presence  we  can  afi&rm  in  our  patients  without 
most  careful  scientific  analysis  and  scrutiny.  "Some  of  them 
understand  the  nature  of  their  disease  quite  well,  discuss  their 
cases  intelligently,  and  frequently  ask  why  they,  automaton-like, 
are  impelled  by  a  force  which  they  cannot  resist  to  constantly  do 
things  which  their  intelligence  and  better  nature  condemn.  Not 
a  few  are  confined  in  places  of  safety  by  their  own  preference." 
(Folsom.) 

It  is  not  to  be  supposed  that  medical  experts  experience  convic- 
tions as  to  the  presence  or  absence  of  mental  aberration  without 
careful  subjection  of  the  data  which  should  mould  their  opinions 
to  the  laws  of  diagnosis  governing  a  recognition  of  all  other 
diseases.  Without  such  a  procedure  their  investigations  would 
be  unworthy  of  scientific  men. 

With  a  careful  adherence  to  such  methods  of  observation,  based 
upon  broad  principles  of  medical  science,  the  deductions  from  cer- 
tain premises  will  be  susceptible  of  proof  and  remain  established 
upon  an  immovable  basis.  Just  as  in  the  diagnosis  of  pneumonia 
auscultation  and  percussion  are  practised  by  the  prudent  physician 
as  aids  in  evaluating  the  rational  symptoms,  so  in  the  diagnosis 
of  emotional  insanity  all  the  facts,  including  an  attentive  study 
of  all  collateral  phenomena,  must  be  collectively  weighed.  What, 
then,  are  the  logical  deductions  upon  which  we  may  predicate  an 
opinion  of  this  form  of  insanity  ? 

1.  Hereditary  predisposition  is  one  of  the  many  important  links 
of  the  pathological  chain  of  sequences  which  has  to  be  developed 
in  the  diagnosis,  and  is  one  to  which  the  physician  should  first 
direct  his  attention.  Ancestral  taint,  the  fact  that  the  parentage 
of  the  particular  person  undergoing  investigation  is  tinctured 
with  previously  existing  insanity  or  allied  neurotic  affections, 
must  never  be  lost  sight  of.  Persons  having  such  an  unfortu- 
nate inheritance  are  the  victims  of  a  constitutional  instability  of 


EMOTIONAL   INSANITY.  215 

nervous  equilibrium  which  the  most  trivial  circumstance  may  dis- 
turb.   That  it  is  inherent  in  most  instances,  there  can  be  no  doubt. 

In  emotional  insanity,  as  in  other  maladies,  a  great  many  facts 
are  manifest  which  we  would  not  be  able  to  interpret  but  for  the 
assumption  of  predisposition  or  hereditary  transmission. 

In  many  conditions  of  life  numerous  people  become  insane, 
while  others  subjected  to  exactly  the  same  influences  will  expe- 
rience no  deviation  from  their  normal  mental  health.  This  ten- 
dency to  insanity  is,  therefore,  but  too  frequent  an  heirloom. 

2.  Causation  is  the  next  point  for  consideration  in  our  diag- 
nosis of  emotional  insanity.  Predisposing  causes,  including  sex, 
period  of  life,  condition  of  life,  individual  predisposition,  educa- 
tion, and  many  other  conditions,  must  be  studied. 

Exciting  causes,  subdivided  into  physical  and  moral,  next  de- 
mand attention.  Relegated  to  the  former  are  such  influences  as 
intemperance,  masturbation,  epilepsy,  chronic  diseases  which  dete- 
riorate the  blood,  which  latter  conditions  are  prolific  of  insanity, 
exemplifying  Cicero's  well-known  maxim,  mens  sana  in  corpore 
sano.  Then,  again,  injuries  of  the  head,  lactation,  pregnancy, 
uterine  diseases  or  disturbances,  puberty,  the  climacteric  period, 
all  are  of  the  utmost  significance  in  an  etiological  sense. 

Of  the  moral  causes  Maudsley  asserts  that  "  it  is  not  in  the  way 
of  great  intellectual  exercise,  when  unaccompanied  by  emotion,  to 
lead  to  mental  derangement ;  it  is  when  the  feelings  are  deeply 
engaged,  when  the  mind  is  the  theatre  of  great  passion,  that  it  is 
most  moved  and  its  stability  most  endangered." 

Anxiety,  jealousy,  sorrow,  disappointed  affection  or  ambition, 
are  powerful  factors  in  this  regard.  Causation,  therefore,  plays  a 
most  important  part  in  our  diagnosis. 

But  it  is  more  especially  a  concurrence  of  causes  that  leads  to 
a  development  of  this  form  of  the  disease.  If  we  knew  all  the 
causes  leadino;  to  it,  or  could  foresee  contingencies  which  mav 
arise,  then  we  might  venture  to  predict  it  in  certain  individuals 
or  families  at  particular  periods  of  their  lives. 

However,  as  before  observed,  insanity  does  not  depend  upon 
one,  or  a  few,  but  upon'  a  multiplicity  of  causes ;  and,  as  Mauds- 
ley  remarks,  "  hereditary,  predisposing  moral  and  physical  causes 
are  not  alone  necessary,  but  a  combination,  a  concurrence  of  con- 
ditions, and  then  lunacy  follows." 


216  DISEASES   OF   THE   NEEVOUS  SYSTEM. 

To  recapitulate,  various  potentialities — the  existence  of  disease, 
acute  or  chronic,  which  leads  through  physical  developments  to 
the  production  of  emotional  insanity ;  particular  conditions  of 
the  organism ;  all  varieties  of  physical  deteriorations ;  impaired 
or  impeded  nutrition  ;  poisoned  conditions  of  the  blood  ;  excessive 
functional  activities,  however  produced ;  the  absence  of  sleep ; 
reflex  actions  or  sympathies ;  quantitative  as  well  as  qualitative 
disturbances  of  the  circulation — are  energetic  factors  in  the  pro- 
duction of  mental  disease  of  this  as  of  other  varieties  requiring 
the  psychological  physician's  closest  scrutiny. 

The  development  of  psychic  functions  and  their  conformity 
to  a  physiological  type  require  a  healthy  brain  for  their  proper 
evolution.  Diseased  brains  lead  to  culminations  of  morbid  men- 
tal and  emotional  manifestations  and  phenomenal  deteriorations 
known  as  insanity. 

Brains  intellectually  overworked,  emotionally  over-excited,  like 
jaded  horses  tasked  too  heavily,  suffer  their  functional  activities 
to  be  overwhelmed,  and  without  sufficient  recuperative  powers 
total  ruin  and  wreck  inevitably  follow. 

That  moral  causes,  especially  the  depressing  passions,  should 
prove  energetic  agents  in  the  production  of  mental  disease,  need 
not  excite  our  astonishment.  Moral  shock  not  infrequently  over- 
whelms the  entire  emotional  and  physical  nature  of  the  individual. 
That  powerful  emotions  are  productive  of  disease — nay,  even  death 
— we  all  know.  Medical  literature  is  stored  with  facts  which  prove 
conclusively  that  the  hair  sometimes  turns  gray  in  a  single  night.* 
Maudsley  ("  Body  and  Mind")  observes  "  that  a  sudden  and  great 
mental  shock  may,  like  a  great  physical  shock,  and  jDcrhaps  in  the 
same  way,  paralyze  for  a  time  all  the  bodily  and  mental  functions, 
or  cause  instant  deathj^ 

3.  "  Change  of  character,  without  any  adequate  external  cause" 
is  the  next  link  of  importance  in  the  diagnostic  chain  we  are 
forging,  without  which  all  our  efforts  to  establish  the  existence 
of  emotional  insanity  in  a  given  case  would  be  invalidated.  Its 
importance  is  pre-eminent.  It  is  the  pivot  on  which  the  diagnosis 
turns.  This  change  consists  in  a  departure  from  one's  normal 
self,  not  merely  a  supposititious  or  hypothetical  change,  l^ut  a 

*  Tuke,  "  Influence  of  the  Mind  upon  the  Body." 


EMOTIONAL   INSANITY.  217 

change  established  in  proprld  persond  by  the  rigid  scrutiny  of 
scientific  analysis. 

Daily  actions,  sentiments,  natural  impulses,  propensities,  pas- 
sions, moral  dispositions,  feelings,  affections,  inclinations,  habits, 
are  compared  with  a  normal  standard,  a  departure  from  which 
must  be  evident  to  those  whose  previous  acquaintance  and  inti- 
mate relations  with  the  subject  peculiarly  adapt  them  for  reaching 
proper  and  indisputable  conclusions. 

Under  these  circumstances  reliance  must  unavoidably  be  placed 
by  the  physician  upon  the  experience,  observations,  and  inferences 
of  near  relatives,  who  are  better  qualified  to  judge  of  early  abnor- 
mities or  deviations  of  the  affective  life  than  the  most  skilful 
diagnosticians. 

A  mother,  for  example,  can  certainly  establish  a  change  of 
character  in  her  child  better  than  any  other  person.  The  physi- 
cian must,  however,  satisfy  himself  as  to  the  absence  of  all  pos- 
sible motives  of  action,  and  of  all  other  external  adequate  causes, 
which  in  the  absence  of  disease  could  sufficiently  explain  these 
singularities  of  conduct,  eccentricities  of  action,  and  changes  in 
one's  natural  self,  or  a  departure  from  that  type  previously  char- 
acteristic of  the  individual. 

This  departure  consists  in  a  great  variety  of  gross  or  delicate 
alterations,  which  it  is  the  duty  of  the  physician  to  educe.  These 
must  so  change  the  person  under  investigation  that  he  ceases,  as  it 
were,  to  be  the  same  individual  that  he  was.  I  am  making  no 
reference  to  discoverable  intellectual  perversions.  I  am  simply 
considering  deviations  in  the  affective  life,  presented  only  in  an 
analysis  of  actions,  as  expressive  of  morbid  feelings,  not  of  words, 
as  illustrative  of  disordered  ideas.  The  social,  domestic,  religious, 
and  business  habits  and  antecedents  must  be  scrutinized  mth  the 
utmost  rigidity  and  fulness  of  detail.  Heretofore  an  affectionate 
husband  and  tender  father,  the  caresses  lavished  upon  his  family 
cease  ;  he  repels  the  advances  of  his  little  flock  which  before  con- 
stituted his  delight ;  there  is  a  sad  revolution  in  his  home  life,  and 
the  dear  ones  of  his  fireside  are  the  first  to  recognize  the  stem 
reality  which  confronts  them.  This  recognition  of  the  patient's 
abnormal  condition  occurs  long  prior  to  any  overt  act  of  insanity 
or  explosive  violence. 

The  bursting  of  the  storm  is  long  anticipated,  however,  by  the 


218  DISEASES   OF   THE   NERVOUS  SYSTEM. 

keen  perception  of  those  whose  intimate  relations  with  the  patient 
have  caused  them  to  realize  its  direful  foreshadowings.  So  in  all 
other  conditions  of  life,  whether  social  or  domestic,  these  changes 
will  be  perceptible. 

Men  of  strong  religious  natures  and  convictions  suddenly  be- 
come rash,  intemperate,  obscene,  desperate,  and  utterly  depraved. 
Such  transitions  develop  themselves  without  any  reason  assignable 
by  the  most  intimate  companions. 

An  eminent  and  learned  divine,  distinguished  for  social  virtue, 
high  and  charitable  religious  aspirations  and  disinterestedness,  the 
centre  of  attraction  and  the  adulation  of  his  flock,  admired,  loved, 
and  respected  by  all,  suddenly,  loithout  external  adequate  cause,  be- 
comes irreligious,  intemperate,  profligate,  and  wretchedly  dissi- 
pated. If,  moreover,  without  notice,  he  indulge  homicidal  or 
suicidal  propensities  of  recent  development,  we  would  judge  him 
either  a  confirmed  lunatic  or  previously  a  consummate  hypo- 
crite ;  for  the  study  of  his  life  must  confirm  one  or  the  other 
hypothesis. 

Or  suppose  a  parsimonious  man,  taking  care  of  every  dime,  ex- 
hibiting a  ceaseless  and  sleepless  solicitude  for  his  worldly  goods, 
never  giving  or  expending  anything  except  for  the  absolute  neces- 
sities of  life,  were  suddenly,  without  adequate  motive,  to  become 
excessively  liberal,  squandering  his  money  as  recklessly  as  formerly 
he  had  carefully  hoarded  it,  would  not  such  conduct  point  to  a 
most  suspicious  perversion  of  feeling,  and  to  a  change  of  sentiment 
consistent  only  with  emotional  insanity  ?  Hence  the  significance 
of  actions  when  contrasted  with  the  previous  conditions  or  ante- 
cedents of  a  patient. 

The  foregoing  illustrations  especially  indicate,  therefore,  the  de- 
velopment of  insanity  of  the  affective  type,  without  any  particular 
concomitant  evidences  of  the  existence  of  morbid  intellection. 

In  business  relations,  if  heretofore  one  has  been  honest,  upright, 
reliable,  a  representative  man  in  his  sphere  of  life,  whether  com- 
mercial or  professional,  a  change  so  perceptible  will  manifest  itself 
as  to  cause  his  acquaintances  to  be  staggered  at  its  completeness 
and  suddenness.  The  perturbation  of  his  moral  nature  will  be 
evident  to  his  most  casual  acquaintances. 

But,  gentlemen,  think  you  this  is  all  to  be  considered  in  this 
connection  ? 


EMOTIONAL   INSANITY.  219 

Wlien  you  essay  to  diagnosticate  emotional  insanity,  you  must 
not  only  dip  deeply  into  the  questions  I  have  already  presented 
for  your  study,  but  you  must  investigate  all  proved  morbid  ten- 
dencies with  equal  thoroughness.  Suicidal  and  homicidal  propen- 
sities are  particularly  to  be  examined.  When  such  tendencies — 
without  a  motive — are  proved,  they  constitute  strong  corroborative 
proof  of  the  existence  of  insanity. 

Such  links  being  necessary  to  establish  the  existence  of  emotional 
insanity,  we  can  but  regret  and  deprecate  opinions  that  once  in- 
fluenced a  jury  in  a  celebrated  trial  in  the  State  of  New  York  to 
bring  in  the  absurd  verdict  that  a  man  was  sane  one  moment  prior 
to  the  commission  of  the  homicide,  insane  during  the  homicide,  and 
sane  immediately  subsequent  to  the  act. 

Such  opinions  bring  science  into  disrepute  and  prostitute  the 
plea  of  insanity,  exciting  the  clamor  of  popular  prejudice  when, 
in  the  great  cause  of  humanity,  mental  alienation  is  sought  to  be 
proved  in  genuine  cases. 

4.  "  Want  of  harmony  of  the  individual  with  his  surroundings.'^ 
"  It  is  important,  therefore,  that  we  have  in  remembrance  the  in- 
dividual's social  relations  when  dealing  with  moral  insanity,  as  we 
regard  the  very  diiferent  relations  of  an  epithelial  cell  and  a 
nerve-cell  when  dealing  with  structures  so  far  apart  in  the  scale  of 
life.  It  is  chiefly  in  the  degeneration  of  the  social  sentiments  that 
the  symptoms  of  moral  insanity  declare  themselves ;  it  is  plain  that 
the  most  typical  forms  of  the  disease  can  only  be  met  with  in  those 
who  have  had  some  social  cultivation." 

To  establish  this  is  a  matter  of  the  utmost  importance,  for 
"  the  morbid  phenomena  of  the  diseased  mind  witness  in  some 
measure  to  the  degree  of  its  previous  development,  yet  the  de- 
generation which  disease  implies  must  needs  display  itself  in  an 
alteration  in  the  kind  of  manifestation  of  feeling,  thinking,  and 
acting, — in  other  words,  in  a  changed  self, — while,  again,  the 
import,  as  morbid,  of  the  phenomena  displayed,  can  only  be 
rightly  weighed  in  relation  to  the  individual  sphere  cf  life.  It  is, 
for  example,  quite  possible,  though  apt  to  be  forgotten  in  practice, 
that  sentiments  and  acts  which  are  habitual  in  the  lowest  station  of 
life  may  be  sure  signs  of  mental  disease  lohen  uttered  and  done  by 
one  in  a  high  social  sphere.^' 

There  is  under  such  circumstances  a  want  of  congruity  in 


220  DISEASES   OF   THE   NERVOUS  SYSTEif. 

social  relations,  a  want  of  adaptation  between  the  general  and 
particular  social  harmony  of  the  individual.  "  A  cancer  is  physio- 
logically illogical;  nevertheless  it  persists,  and  finally  kills  the 
patient,  being  pathologically  logical." 

The  individual  who  no  longer  constitutes  a  part  of  the  general 
harmonious  whole,  for  reasons  "psychologically  accountable,"  is 
no  longer  the  unit  in  the  social  system  which  he  was  prior  to  the 
inroads  of  emotional  perversion.  "  Insanity  destroys  the  rela- 
tions and  responsibilities  of  the  individual  in  the  social  system, 
making  him  very  much  like  what  a  morbid  element  is  in  the 
organic  system, — something  which  cannot  take  its  due  place  in 
the  general  harmony,  and  which  must  either  be  eliminated  from 
it  or  sequestrated  and  rendered  harmless  in  it.'^  "Schopenhauer 
says  that  the  normal  man  is  two-thirds  will  and  one-third  intel- 
lect,— in  other  words,  two-thirds  made  by  education  and  one-third 
by  inheritance.  The  intellect  is  often  trained  so  as  to  enfeeble  the 
■snil  as  well  as  to  hinder  the  development  of  the  physical  man. 
Self-culture  may  so  degenerate  into  self-indulgence  as  to  destroy 
individuality  and  force ;  and  mental  health,  as  a  rule,  depends 
upon  bodily  health  and  the  exercise  of  self-control."     (Folsom.) 

5.  According  to  Maudsley,  whose  views  we  are  developing,  the 
standards  by  which  we  can  measure  the  perversion  are,  first,  that 
of  the  hind,  which  is  fixed  by  the  general  consent  of  mankind ; 
and  secondly,  that  of  the  individual,  which  is  estimated  by  the 
degree  of  his  previous  mental  development. 

Therefore  the  individual  may  frequently  perform  acts  Avhioh 
are  not,  when  compared  with  his  normal  standard  of  action,  in  any 
respect  whatsoever  characteristic  of  insanity ;  or  the  reverse  may 
be  the  case.  There  exists,  therefore,  a  standard  which  the  common 
sense  of  mankind  has  established,  by  means  of  which  all  insane 
perversions  are  to  be  compared,  measured,  and  regulated. 

By  way  of  illustration,  let  us  glance  at  certain  delusions  and  the 
significance  thereto  attached  by  such  a  standard.  If  a  jjatient  tells 
us  that  a  person  came  into  his  room  through  a  key-hole,  although 
he  has  long  been  cognizant  of  the  death  of  such  person,  would  a 
sane  mind  experience  any  difficulty  in  estimating  such  a  vagary  ? 

So  also  in  other  delusions  met  with  during  practical  observation 
of  the  insane, — where  they  imagine,  for  instance,  that  they  are 
made  of  glass,  or  as  in  one  case  which  I  recall  of  a  certain  lady 


EMOTIONAL   INSANITY.  221 

who  believed  that  she  was  an  hour-glass,  and  would  request,  after 
the  saud  had  run  down  during  a  certain  time,  "  to  be  turned  upside 
do^vn,  in  order  to  allow  it  to  run  the  other  way,"  in  such  in- 
stances tlie  evidences  are  so  incontrovertible  as  hardly  to  need  the 
application  of  the  rule  I  have  just  enunciated. 

6.  Corroborative  proofs  of  insanity  often  exist  in  cases  under 
examination.  Assaults  made  upon  beloved  relatives  and  intimate 
friends,  unaccountable  and  baseless  aversions,  especially  when 
accompanied  by  violent  assaults  of  a  homicidal  character,  which 
have  been  perhaps  preceded  by  suicidal  propensities,  are  char- 
acteristic of  the  existence  of  insanity.  Meditative  moods,  aimless 
schemes,  deep  reveries,  fits  of  unusual  abstraction,  peculiarities 
and  eccentricities  of  dress,  want  of  tenacity  of  purpose  in  persons 
previously  firm,  indecent  exposures,  desire  to  remain  nude,  self- 
mutilation,  talking  to  one's  self,  squandering  property,  obscenity, 
filthy  practices,  destructive  and  intemjDerate  habits,  are  all  charac- 
teristic of  insane  people. 

7.  The  physical  symptoms  of  insanity  should  be  diligently  sought 
in  all  equivocal  cases  of  emotional  insanity, — viz.,  headache,  in- 
somnia, restlessness,  constipation,  et  id  omne  genus.  In  the  con- 
catenation of  circumstances  constituting  the  links  of  the  chain  of 
evidence,  the  careful,  prudent  physician  will  make  patient  and 
thorough  inquiries  in  all  the  directions  enumerated  before  an- 
nouncing his  opinion  from  the  witness-stand.  If  all  heretofore 
stated  be  true,  the  diagnosis  of  emotional  insanity  is  of  a  very 
complicated  character,  and  the  physician  who  makes  it  should 
divest  himself  of  all  partiality  and  subject  the  analysis  of  his  case 
to  the  closest  scrutiny  of  scientific  investigation.  In  other  Avords, 
like  any  other  diagnosis  in  the  field  of  medical  inquiry,  it  should 
rest  solely  upon  the  merits  of  the  naked  facts. 

DIVISION  OF  INSANITY  INTO  TWO  PEINCIPAL  GEOUPS, — (a) 
AFFECTIVE  OR  EMOTIONAL  INSANITY,  (6)  IDEATIONAL  OE 
INTELLECTUAL   INSANITY.       (MAUDSLEY.) 

In  a  former  lecture  I  sjjoke  of  the  division  of  insanity  into 
two  primary  groups,  naturally  characterized  by  variations  of  the 
disease,  as  affecting  either  the  loords  or  the  acts  of  an  individual. 
A  person  may  be  insane  in  his  words  or  in  his  actions ;  and  this 
difference  admits  of  a  division  of  insanity  into  ideational  and 


222  DISEASES   OF   THE   NERVOUS   SYSTEM. 

affective, — ideational  insanity  being  evinced  by  irrational  words, 
and  the  affective  form  by  abnormal  actions,  which  are  the  mani- 
festations or  outcroppings  of  insane  feelings.  These  facts  we  now 
propose  to  study ;  and  they  are  veiy  significant.  Indeed,  if  you 
have  succeeded  in  realizing  this  distinction,  you  have  already 
mastered  an  imp<3rtant  preliminary  in  the  study  of  this  subject. 

We  have,  then,  ideational  and  affective  insanity  ;  the  latter — 
also  called  the  pathetic — pointing  to  impulses  of  perverted  volition, 
the  former  evinced  by  irrational  conversation  or  incoherent  and 
erroneous  reasoning.  We  might  call  this  a  disease  of  ideas 
(assuming,  however,  that  they  are  immaterial),  but  we  have  refer- 
ence, of  course,  to  insane  words  in  consequence  of  the  affection 
of  the  cortical  cells  employed  in  the  elaboration  of  thought. 
Hence  the  individual  is  ideationally  insane,  and  can  no  longer 
think  normally,  this  deficiency  being  manifested  not  in  his  actions 
but  in  his  words.  We  find,  moreover,  that  these  groupings  are 
not  peculiar  to  any  one  of  the  forms  of  insanity,  but  to  all  of 
them,  so  that  we  may  have  either  mania  or  melancholia  of  the 
ideational  type,  or  of  the  affective  type,  or  of  both.  I  want  you  all 
to  understand  this  fact,  which  is,  according  to  the  best  authorities, 
that  in  any  given  case  the  insanity  may  partake  either  of  one 
or  of  both  of  these  types.  Melancholia  may  therefore  exist,  and 
evince  only  a  disturbance  of  the  feelings ;  but  if  it  coexist  with 
delusions  there  is  then  a  complication  of  the  ideational  with  the 
affective  type,  and  mental  action  becomes  perverted.  On  the  other 
hand,  a  person  may  have  mania  or  melancholia  with  delusions,  and 
this  will  necessarily  imply  an  erroneous  ideation  with  aberration 
of  sentiment,  as  expressed  by  both  words  and  actions. 

I  shall  not  attempt  in  this  lecture  to  detail  the  varied  and 
numerous  classifications  of  insanity.  Maudsley's  division  of  the 
subject  into  two  principal  groups,  the  ideational  and  the  emo- 
tional, is  the  greatest  advance  that  has  ever  been  made  in  this 
direction,  and  recommends  itself  by  its  intelligibility  and  sim- 
plicity. With  the  ideational  or  intellectual  variety  we  have 
nothing  to  do  in  this  lecture. 

Cases  presenting  delusions,  hallucinations,  illusions,  dementia, 
and  other  perversions  of  the  intellect  must  necessarily  admit  of 
easy  interpretation.  On  the  other  hand,  disturbances  of  the  emo- 
tional or  affective  life  may  give  rise  to  the  greatest  discrepancy  of 


EMOTIONAL   INSANITY.  223 

opinion,  and,  I  am  sorry  to  say,  even  to  conflicting  and  contra- 
dictory statements  upon  the  part  of  medical  men.  It  should  be 
understood  that  aflFective,  pathetic,  and  emotional  insanity  are 
synonymous  expressions  defining  one  primary  group,  of  which 
moral  and  impulsive  insanity  are  only  subdivisions.  The  acts 
alone  in  all  their  manifestations  form  the  subject  of  our  inquiries. 

It  is  necessary,  gentlemen,  to  impress  upon  your  minds  at  this 
juncture  a  matter  somewhat  perplexing  until  properly  explained, 
one  that  even  medical  men  not  sufficiently  familiar  wdth  the 
changeful  manifestations  of  insanity  but  too  frequently  overlook, 
— namely,  that  the  existence  of  mtellectual  insanity  points  to  a 
perverted  or  disturbed  condition  of  thought,  and  wherever  this 
exists  a  disordered  state  of  ideas  will  exhibit  itself  in  the  words 
of  the  patient  as  expressive  of  morbid  ideas. 

Whenever,  on  the  contrary,  the  emotional  faculties  are  distorted, 
discordant  acts  springing  from  disordered  feelings  force  themselves 
upon  our  attention  as  the  phenomena  to  be  studied  and  investi- 
gated. How  do  we  manifest  our  feelings?  Is  it  not  by  our 
actions  ?  "  Feelings  mirror  the  real  nature  of  the  individual,  and 
are  the  springs  of  action."  Therefore,  as  you  study  perverted 
thought  by  the  expression  of  incoherent  words,  so  are  you  to  study 
the  disturbances  which  exist  in  the  affective  or  emotional  faculties 
by  the  development  of  insane  acts. 

Hence  in  some  forms  of  insanity  all  the  phenomena  must  be 
studied  by  insane  words ;  in  other  forms — of  almost  unlimited 
variety  and  shading — by  insane  actions  alone. 

In  addition  to  this  it  might  be  stated  that  the  fundamental  state 
associated  more  or  less  directly  with  all  forms  of  insanity  is  per- 
version of  the  affective  life;  it  is  the  underlying  current  which 
influences  and  moulds  all  varieties  of  the  affection. 

Persons,  at  the  commencement,  generally  become  insane  through 
a  want  of  proper  co-ordination  of  their  feelings.  This  is  the  first 
step  outside  the  limits  of  mental  health.  Affective  insanity  is  the 
deeply-rooted  morbid  state,  of  which  all  the  other  phenomena  are 
the  outcroppings.  Hence  intellectual  insanity  is  nearly  always 
preceded  by  the  affective  form.  Again,  if  the  intellectual  form  be 
■developed,  it  is  usually  in  combination  with  the  affective  form,  and, 
if  it  be  cured,  the  affective  forra  generally  lingers,  and  is  the  last  to 
disappear.     We  can  now  understand  that  the  affective  or  emotional 


224  DISEASES  OF   THE   NERVOUS   SYSTEM. 

form  of  insanity  is  the  fundamental  condition  with  which  we  must 
thoroughly  familiarize  ourselves  in  order  fully  to  comprehend  all 
the  bearings  and  collateral  facts  connected  with  the  philosophical 
study  of  the  general  subject.  Affective  or  emotional  perver- 
sions, therefore,  are  the  precursors  of  all  phenomena  culminating 
in  convulsive  action  and  moral  irresponsibility.  Esquirol  holds 
"moral  alienation  to  be  the  proper  characteristic  of  mental  de- 
rangement." "  There  are  madmen,"  he  says,  "  in  whom  it  is 
difficult  to  find  any  trace  of  hallucination,  but  there  are  none  in 
whom  the  passions  and  moral  affections  are  not  perverted  and 
destroyed.  I  have  in  this  particular  met  with  no  exceptions." 
Maudsley,  in  commenting  on  this  quotation,  adds,  "  This  expe- 
rience is  in  entire  accord  with  that  of  every  observer  of  insanity, 
and  with  the  principles  of  a  sound  psychology.  It  is  the  feelings 
that  reveal  the  genuine  nature  of  an  individual ;  it  is  from  their 
depths  that  the  impulses  of  action  are  born,  while  the  intellect 
guides  and  controls ;  and,  accordingly,  in  a  perversion  of  the 
affective  life  is  revealed  a  fundamental  disorder  of  the  innermost 
nature,  a  disorder  which  will  be  exhibited  in  acts,  as  opposed  to 
intellectual  disorder,  which  will  be  exhibited  in  words." 

"To  insist  upon  the  existence  of  a  delusion  as  a  criterion  of  in- 
sanity is  to  ignore  some  of  the  gravest  and  most  dangerous  forms 
of  mental  disease.''"^ 

The  importance  of  an  analysis  of  the  feelings  in  the  study  of 
insanity  cannot,  therefore,  be  exaggerated.  The  deep,  occult  sub- 
tleties of  emotional  life  constitute  the  open  sesame  to  psychological 
inquiry.  "  By  his  acts,  as  well  as  by  his  speech,  does  man  utter 
himself;  gesture-language  is  as  natural  a  mode  of  expression  as 
speech ;  and  it  is  in  insanity  of  action  that  this  most  dangerous 
form  of  affective  insanity  is  expressed, — most  dangerous,  indeed, 
because  so  expressed." 

His  actions  are,  therefore,  the  mirrors  of  his  feelings,  the  out- 
comings  of  the  innermost  recesses  of  his  nature,  of  that  uncon- 
scious activity  which  so  often  moulds  imperceptibly,  but  surely, 
the  destinies  of  man. 

Men,  therefore,  are  sometimes  unquestionably  unable  to  act 
rationally,  normally,  and   consistently,  being,  from   deep-seated 

*  Italics  my  own. 


EMOTIONAL   INSANITY.  225 

perversion  of  the  affective  life,  insane.  We  all  study  individuals 
through  tlieir  actions.  Inborn,  unconscious  influences  "  sway  the 
pendulum  of  life  from  the  cradle  to  the  grave." 

We  need  not  wonder  that  affective  insanity  is  the  most  dangerous 
form  of  madness  ;  a  man  with  delusions  or  other  evidence  of  in- 
tellectual aberration  is  soon  locked  up,  but  a  man  emotionally 
insane  too  often  commits  some  overt  act  of  violence  before  he 
sufficiently  attracts  attention  to  make  public  opinion  demand  his 
sequestration.  Not  that  I  attach  undue  importance  to  a  given  act. 
On  the  contrary,  as  I  have  stated  before,  I  believe  no  isolated  act 
in  itself  capable  of  proving  insanity,  no  matte?'  how  great  its  enor- 
mity, its  absence  of  motive,  or  its  other  unaccountable  features. 

Suicidal  and  homicidal  propensities,  erotomania,  kleptomania, 
pyromania,  etc.,  do  not  per  se  constitute  distinct  forms  of  insanity, 
as  was  formerly  taught.  On  the  contrary,  I  believe,  with  Maudsley 
and  Blandford,  that  such  conditions  are  but  purely  symptomatic 
indications  of  a  previously  existing  insanity. 

Blandford  says,  "  Besides  the  homicidal  monomania,  we  hear 
of  others,  as  erotomania,  kleptomania,  and  pyromania.  Having 
already  stated  that  I  do  not  consider  homicidal  monomania  to  be 
a  specific  disease,  I  still  less  acknowledge  that  the  acts  which  these 
terms  indicate  proceed  from  special  disorders.  They  are  com- 
mitted by  insane  patients  of  various  kinds ;  the  insanity  is  not 
likely  to  be  confined  to  one  of  these  acts,  but  is  sure  to  be 
noticeable  in  other  ways,  if  it  exist  at  all. 

"  To  take  the  last  one  mentioned,  pyromania,  we  might  as  well 
erect  into  a  special  form  the  window-breaking  mania,  etc." 

Maudsley  observes,  "  So  far  from  the  morbid  impulse  or  act 
constituting  insanity,  it  is  but  the  outward  and  visible  sign  or 
expression  of  a  profound  affective  derangement,  the  tendency  of 
which  is  to  manifest  itself,  not,  as  ideational  insanity  does,  in 
words,  but  in  acts,  and  which  for  this  very  reason  is  much  more 
dangerous  than  ideational  insanity. 

"  So  far  from  the  disease  being  simply  a  homicidal  or  suicidal 
insanity,  it  is  truly  an  affective  insanity,  one  symptom  of  which  is 
homicidal  or  suicidal  impulse  ;  the  delusion,  when  there  is  one, 
and  the  homicidal  acts  are  later  symptoms  of  a  deeper-lying  disease  ; 
and  the  morbid  manifestation  of  one  may  be  as  little  within  control 
as  that  of  the  other,  or  as  the  suddenly-arising  hallucination  is. 

15 


226  DISEASES   OP   THE   JSTERVOUS   SYSTEM. 

In  the  one  case  he  is  the  victim  of  a  morbid  idea  ;  in  the  other,  of 
a  morbid  movement ;  in  both  cases,  of  a  convulsion  more  or  less 
co-ordinate." 

Hence  if  we  attached  undue  importance  to  isolated  acts  we 
should  sometimes  mistake  for  a  disease  what  is  only  a  symptom. 
To  establish  a  diagnosis  under  such  circumstances  necessitates  the 
discovery  of  other  symptoms,  otherwise  the  significance  of  an 
isolated  act  would  not  be  invalidated. 

If  the  public  could  be  made  to  appreciate  this  fact,  there  would 
be  less  prejudice  against  the  plea  of  emotional  insanity,  and  less 
effort  upon  the  part  of  lawyers  to  bring  it  into  contempt  by  its 
constant  prostitution.  The  diagnosis  of  emotional  insanity  rests 
necessarily  upon  so  many  different  proofs  as  to  make  it  no  very 
easy  matter  to  establish  it  beyond  all  possible  cavil.  Unless  it 
can  rest  upon  the  laws  of  diagnosis  which  apply  to  all  other  dis- 
eases, it  should  not  for  a  moment  be  regarded  as  established. 

Emotional  insanity  is  therefore  known  to  exist  by  the  history  of 
the  case,  the  existence  of  hereditary  pixdisposition,  the  presence  of 
some  of  the  well-known  conditions  of  causation,  the  change  of  char- 
acter, the  cessation  of  social  harmony  with  surroundings,  the  cor- 
roborative circumstances,  the  impaired  judgment  of  relations,  the 
measuring  of  the  perversion  according  to  an  individual  standard,  or 
to  one  accepted  by  the  common  setise  or  the  general  consent  of  man- 
kind, the  motiveless  assaults  upon  relatives  and  intimate  friends,  the 
existence  of  some  of  the  physical  symptoms  of  insanity ;  in  other 
words,  our  diagnosis  is  to  be  based  upon  all  the  above-mentioned 
states,  the  etiological  conditions,  the  sequence  of  symptoms,  and  the 
general  course  of  the  affection. 

If  you  have  grasped  these  facts,  you  are  in  possession,  gentle- 
men, of  the  most  important  part  of  this  subject ;  and,  to  recapitu- 
late in  a  concise  manner,  I  will  say  that,  as  in  emotional  insanity 
the  feelings  are  first  affected,  it  is  through  them  we  must  study  all 
collateral  phenomena.  When  a  truly  insane  person  commits  homi- 
cide, suicide,  rape,  or  arson,  it  is  the  result  of  some  serious  form  of 
insanity,  such  acts  never  constituting  the  insanity  per  se.  They 
are,  therefore,  merely  the  outcroppings  or  symptomatic  manifesta- 
tions of  a  morbid  condition  of  the  emotional  nature ;  and  delu- 
sions are  by  no  means  the  only  evidences  distinctive  of  mental 
disease,  but  are  simply  symptomatic  of  ideational  insanity. 


EMOTIONAL   INSANITY.  227 

Overt  acts  of  violence  indicate  a  morbid  condition  of  feeling  ; 
incoherent  words,  a  morbid  condition  of  thought ;  or,  to  make  it 
plain,  just  as  insane  words  are  produced  by  insane  thoughts,  so  are 
insane  acts  produced  by  insane  feelings. 

But  some  of  you  may  inquire  why  it  is  that  a  person  may  be  the 
victim  of  aifective  insanity  only,  and  not  necessarily  intellectually 
insane  at  the  same  time. 

In  reply  I  would  state  that  such  is  the  case  for  the  same  reason 
that  inflammatory  conditions  sometimes  remain  in  statu  quo,  some- 
times advance,  sometimes  recede.  Is  inflammation  always  followed 
by  ulceration,  sloughing,  suppuration,  or  gangrene  ? 

So  in  a  psychological  development  the  fundamental  or  affective 
form  of  insanity  may  exist  alone;  there  may  never  be  devel- 
oped during  the  case  any  manifestation  of  ideational  insanity  to 
complicate  the  situation  ;  the  disease  may  not  proceed  so  far. 

DIVISIONS   OF   AFFECTIVE   INSANITY. — MORAL   INSANITY. 

You  have  heard,  gentlemen,  perhaps  not  very  understandingly, 
that  moral  insanity  and  impulsive  influences  may  lead  persons 
instinctively  to  perform  atrocious  acts.  I  will  discuss  the  sub- 
jects of  moral  and  impulsive  insanity  in  a  few  words,  first  taking 
up  that  of  moral  insanity. 

Let  me  affirm,  once  for  all,  that  "  moral  insanity  is  never  moral 
depravity"  and  that  in  order  to  establish  the  existence  of  moral 
insanity  the  physician  regulates  himself  by  precisely  the  same  rules 
of  diagnosis  to  which  I  have  so  recently  referred  in  the  discussion 
of  other  forms  of  insanity.  Of  late  years  I  have  believed,  not- 
withstanding the  doctrines  of  Pritchard,  that  a  careful  study  of 
moral  insanity  will  enable  us  to  detect  some  evidences,  although,  it 
must  be  confessed,  often  very  feeble,  of  mental  weakening.  Even 
the  classic  cases  of  Pritchard,  who  first  defined  the  so-called  moral 
insanity,  when  carefully  examined,  will  confirm  this  statement. 
One  thing,  however,  is  certain, — namely,  that  moral  insanity,  a 
revulsion  more  or  less  sudden  of  the  emotional  nature,  of  course 
produced  by  disease,  like  all  other  forms  of  insanity,  is  preceded 
by  certain  physical  conditions,  such  as  hereditary  taint,  epilepsy, 
suicidal  attempts,  "  the  insane  temperament,"  and  other  influences 
which  are  to  be  taken  into  consideration.     During;  our  tentative 


228  DISEASES   OF   THE   NEEVOUS   SYSTEM 

efforts  of  examination,  the  diagnosis,  therefore,  can  become  estab- 
lished upon  an  unquestionable  basis  only  by  an  investigation  of 
all  the  collateral  and  combined  facts  which  lead  to  the  development 
of  moral  insanity.  Blandford  says  that "  we  meet  with  that  form 
of  insanity  called  moral  when  the  patient,  either  on  the  high  road 
to  intellectual  insanity  or  stopping  short  of  delusions,  shows  his 
insanity  in  insane  acts  which  he  justifies  in  general  alteration  of 
character  and  intellectual  defect.^ '"^ 

If  a  divine  distinguished  for  sanctity,  grown  gray  in  the  ser- 
vice of  the  church,  suddenly,  unaccountably,  without  adequate 
cause,  commenced  to  steal,  became  profane  and  obscene,  would  we 
not  suspect  insanity  ?  On  the  contrary,  innate  parsimony,  mean- 
ness, pusillanimity,  suddenly  and  inexplicably  replaced  by  lavish 
generosity,  princely  prodigality,  magnanimity,  and  heroic  courage, 
would  more  than  awaken  a  suspicion  of  disease  in  our  minds. 
Under  such  circumstances,  would  not  the  most  sceptical  be  con- 
vinced of  the  existence  of  insanity,  which  always  implies  a  change 
in  one's  normal  self  in  consequence  of  disease  f 

IMPULSIVE   INSANITY. 

In  this  condition  there  is  a  development  of  that  blind,  sudden, 
instinctive  action  very  analogous  to  that  which  sometimes  occurs 
under  epileptic  influences. 

There  are  strong  and  irresistible  impulses  to  kill  or  destroy,  or 
to  attempt  self-destruction  and  mutilation.  Evidences  of  mental 
aberration  are  generally  wanting.  The  victims  of  this  form  of 
insanity  are  haunted  night  and  day  by  such  morbid  propensities, 
which  they  frequently  do  not  fully  comprehend  or  appreciate,  and 
sometimes  even  make  strenuous  eiforts  to  resist. 

Those  outside  of  asylums  will  sometimes  voluntarily  subject 
themselves  to  confinement  in  order  to  prevent  the  indulgence  of 
their  impulses.  Inmates  of  asylums  will  in  some  instances  request 
that  mechanical  restraint  be  enforced  upon  them  with  the  same 
object  in  view.  The  victims  of  impulsive  insanity  are  relent- 
lessly persecuted  by  their  furious,  passionate,  and  violent  pro- 
pensities. These  vicious  inclinations  constantly  tend  to  express 
themselves  in  action,  which,  sooner  or  later,  completely  dethrones 

*  Italics  my  own. 


EMOTIONAL   INSANITY.  229 

the  volitional  faculty,  and  manifests  itself  in  explosive  violence, 
or,  as  Maudsley  contends,  in  convulsive  phenomena. 

The  secret,  then,  of  the  psychological  interpretation  of  this 
subdivision  of  emotional  insanity  is  annihilation  of  the  will-power, 
which,  in  point  of  fact,  constitutes  the  very  essence  of  all  insane 
acts.  The  particular  perversions  of  the  affective  life  are  moulded 
into  actions  which  are  not  controlled  or  regulated  by  the  will. 

Of  course  the  diagnosis  of  impulsive  insanity  is  based  upon  the 
same  irrevocable  laws  already  dwelt  upon,  and  which  are  the 
natural  basis  of  all  the  other  varieties  of  insanity.  With  every 
inducement,  therefore,  to  avoid  a  criminal  act,  and  with  a  complete 
knowledge  of  its  wickedness,  a  man  is  nevertheless  compelled 
to  perform  it.  "  There  is  no  relief  for  the  pent-up  destructive 
energy  but  in  an  irresistible  utterance  of  action."  It  is  such  cases, 
therefore,  that  give  rise  to  serious  medico-legal  contests. 

The  impulsive  variety,  I  believe,  is  never  the  first  evidence  of 
insanity.  Dr.  Blanclford  says,  "  I  think  you  will  find,  if  you  go 
to  the  root  of  the  matter,  the  act  which  is  supposed  to  be  com- 
mitted under  the  influence  of  insane  impulse  is  rarely,  if  ever,  the 
first  symptom  of  insanity  or  brain-affection  shown  by  the  alleged 
lunatic.  You  may  be  told  by  friends  that  they  have  never  seen 
any  insanity  in  him ;  but  some  people  cannot  see  it  in  five  out  of 
six  patients  in  an  asylum.  If  you  get  sufficient  information,  you 
will  probably  discover  that  he  has  had  former  attacks,  from  which 
he  may  or  may  not  have  been  considered  as  recovered."  Sankey, 
as  quoted  by  Sheppard,  says,  "I  have  taken  the  precaution  to 
read  a  large  collection  of  reports,  published  from  time  to  time  in 
the  Annales  3ISdico-Psychologiques,  upon  the  state  of  the  mind 
of  persons  accused  of  different  acts  of  violence.  I  have  never  yet 
discovered  a  case  in  which  an  act  of  violence  was  committed  by  a 
lunatic  as  his  first  insane  act.^  There  are  cases  in  which  the 
patient  was  not  considered  insane  by  his  own  relatives,  or  by  in- 
experienced practitioners,  but  who,  on  the  closer  scrutiny  of  the 
physician  who  had  studied  insanity,  was  clearly  proven  to  have 
been  so  for  a  long  period."  The  burden  of  proof  as  to  the  exist- 
ence of  impulsive  insanity,  therefore,  rests  upon  the  ordinary  laws 
of  medical  diagnosis.     Maudsley  says  that  "  there  are  not  only 

*  Italics  my  own. 


230  DISEASES   OF   THE   NEEVOUS  SYSTEM. 

perverted  appetites,  but  there  are  perverted  feelings  and  desires, 
rendering  the  individual  a  complete  discord  in  the  social  organiza- 
tion. The  morbid  appetites  and  feelings  of  hysterical  women  and 
the  singular  longings  of  pregnancy  are  mild  examples  of  a  per- 
version of  the  manner  of  feeling  and  desu'e,  which  may  reach  the 
outrageous  form  of  morbid  appetite." 

As  an  illustration  of  impulsive  insanity  I  quote  the  following 
from  Maudsley :  "  An  old  lady,  aged  seventy-two,  who  had  several 
members  of  her  family  insane,  was  afflicted  with  recurring  parox- 
ysms of  convulsive  excitement,  in  which  she  always  made  des- 
perate attempts  to  strangle  her  daughter,  who  was  very  attentive 
to  her,  and  of  whom  she  was  very  fond.  Usually  she  sat  quiet,  de- 
pressed and  moaning  because  of  her  condition,  and  was  apparently 
so  feeble  as  scarcely  to  be  able  to  move.  Suddenly  she  would  start 
up  in  great  excitement,  and,  shrieldng  out  that  she  must  do  it,  make 
a  rush  upon  her  daughter,  that  she  might  strangle  her.  During 
the  paroxysm  she  was  so  strong  and  writhed  so  actively  that  one 
person  could  not  hold  her  ;  but  after  a  few  minutes  she  sank  down 
exhausted,  and,  panting  for  breath,  would  exclaim, '  There  !  there  ! 
I  told  you  ;  you  would  not  believe  how  bad  I  was.'  No  one  could 
detect  any  delusion  in  her  mind. 

"  The  paroxysm  had  all  the  appearance  of  a  mental  convulsion, 
and,  had  she  unhappily  succeeded  in  her  frantic  attempts,  it  would 
certainly  have  been  impossible  to  say  honestly  that  she  did  not 
know  that  it  was  wrong  to  strangle  her  daughter.  In  fact,  it  was 
because  of  her  horrible  propensity  to  so  wrong  an  act  that  she  was 
so  wretched. 

"  It  is  a  sufficiently  striking  commentary  on  the  present  state 
of  the  English  law,  that,  had  this  patient  succeeded  in  taking  her 
daughter's  life,  sentence  of  execution  must  have  been  passed,  and 
might  have  been  carried  into  effect,  notwithstanding  she  was  so 
entirely  insane  and  irresponsible." 

In  the  family  of  Baron  von  Humboldt,  on  one  occasion  his  wife, 
on  returning  home,  found  the  servant  in  tears,  who  immediately 
threw  herself  on  her  knees  and  confessed  her  inability  to  remain 
in  the  house  on  account  of  an  irresistible  desire  to  kill  their  little 
child.  This  propensity  she  attributed  to  the  whiteness  of  its  flesh, 
which  incited  her  homicidal  tendency  whenever,  whilst  bathing 
and  dressing  the  child,  she  was  left  alone  with  it. 


EMOTIONAL  INSANITY.  231 

Maudsley  quotes  Schenck  as  relating  "  the  history  of  a  pregnant 
female,  in  whom  the  sight  of  a  bare  arm  of  a  baker  excited  so  great 
a  desire  to  bite  and  devour  it  that  she  compelled  her  husband  to 
offer  money  to  the  baker  to  allow  her  only  a  bite  or  two  from  his 
arm.  He  mentions  another  pregnant  female,  who  had  such  an 
urgent  desire  to  eat  the  flesh  of  her  husband  that  she  killed  him 
and  pickled  the  flesh,  that  it  might  serve  for  seveyxd  banquets."  * 

I  would  surpass  the  limit  allotted  to  this  lecture  were  I  to  fur- 
nish further  illustrations  of  impulsive  insanity.  You  can  consult 
the  literature  of  the  subject,  which  abounds  in  them. 

MEDICO-LEGAL   ASPECTS   OF   EMOTIONAL   INSANITY. 

To  the  community  at  large,  the  plea  of  insanity  is  one  of  the 
utmost  importance.  The  medical  witness,  therefore,  has  a  double 
duty  to  perform, — -justice  to  the  community,  and  justice  to  the 
prisoner  at  the  bar :  society  demands  protection  against  crime 
and  violence,  while  the  prisoner,  if  insane,  has  not  forfeited  his 
claims  upon  our  humanity.  The  abuse  of  the  plea  of  insanity 
at  the  present  day  is  fraught  with  great  evils,  and  the  plea  itself 
is.  therefore  constantly  derided  by  the  press  and  the  public. 

Yet  I  am  convinced  that  you  will  not  dispute  the  fact  that 
where  real  insanity  is  proved  it  would  be  most  unjust  to  subject 
to  the  extreme  measures  of  the  law  a  person  whose  volitional 
powers  are  morbidly  impaired  or  destroyed,  and  who  therefore 
must  be  morally  irresponsible. 

Hence  I  think,  with  Forbes  Winslow,  in  his  "  Plea  of  Insanity," 
that  it  would  be  proper  and  just  to  leave  the  adjudication  of  such 
cases  to  a  commission  of  medical  experts.  This  was  done  with 
very  satisfactory  results  by  the  late  Judge  Primm,  of  this  city,  in 
the  Cronenbold  case,  thereby  saving  the  State  the  expense  of  a 
long  trial  and  doubtful  conviction.  He  organized  a  commission 
of  five  experts,  who  were  empowered  to  examine  witnesses  under 
oath,  and  upon  the  return  they  made  Cronenbold  was  sent  to  an 
insane  asylum,  where  he  still  remains. 

I  am  firmly  convinced  that  simple  justice  requires,  whenever  a 
man,  after  committing  a  homicide,  is  liberated  upon  a  plea  of 
insanity,  that  ipso  facto  he  should  be  sent  to  a  lunatic  asylum  for 

*  Italics  my  own. 


232  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

life,  because  in  case  of  supposed  recovery  no  one  could  assume  the 
responsibility  of  affirming  that  sooner  or  later  his  dangerous  disease 
would  not  recur.  On  the  contrary,  every  physician  is'aware  that 
one  attack  of  insanity  predisposes  to  subsequent  attacks,  and  that 
therefore,  from  the  very  nature  of  the  act,  and  the  probability  of 
its  recurrence  from  the  very  nature  of  this  disease,  if  a  man  have 
once  deliberately  taken  the  life  of  a  fellow-creature  in  consequence 
of  want  of  proper  volitional  control  due  to  the  disease  of  the 
brain  we  term  insanity,  then  for  and  during  his  life  he  should  be 
deprived  of  liberty  and  never  again  be  afforded  a  chance  to 
perpetrate  similar  deeds. 

The  liberation  of  Joseph  Fore  in  this  city,  after  being  acquitted 
upon  a  plea  of  emotional  insanity,  was  an  outrage  and  injustice 
which  no  terms  are  strong  enough  to  condemn.  His  tragic  death 
and  subsequent  events  also  conclusively  proved  the  dangerous 
and  destructive  tendencies  of  this  man,  whose  days  should  have 
been  passed  among  the  insane.  Physiciaus  therefore  should  pass 
upon  the  plea  of  insanity,  not  lawyers  or  judges ;  the  former  study 
the  phenomena  of  insanity  with  patience  and  accuracy,  while  the 
latter  are  utterly  ignorant  of  the  necessary  fundamental  knowledge. 

Physicians  are  constantly  with  the  insane ;  they  examine  the 
brain-action  of  those  afflicted  with  mental  disease,  after  having 
made  themselves  thoroughly  acquainted  with  the  laws  of  brain 
physiology.  Clinical,  physiological,  and  pathological  research  pe- 
culiarly constitutes  them  the  interpreters  of  the  manifestations 
and  phenomena  of  the  mind  diseased.  Would  it  not  be  absurd 
to  require  a  physician  to  decide  some  abstruse  and  important  legal 
question,  some  mechanical  problem,  or  metaphysical  proposition  ? 

Who  is  more  familiar  with  all  the  phases  and  complications 
of  mental  alienation  than  the  psychological  physician?  There- 
fore, is  it  to  be  wondered  at  that  such  irreconcilable  antagonisms 
exist  between  medical  and  legal  minds,  and  such  vexatious  con- 
tentions upon  this  sea  of  emotional  insanity  ?  These  antagonisms 
are  the  more  to  be  regretted  because  those  who  from  their  studies 
and  vocation  must  necessarily  keep  abreast  of  the  progress  con- 
stantly being  made  in  the  field  of  psychological  medicine,  who 
are  particularly  and  ^practically  adapted,  therefore,  to  examine 
into  these  questions,  continually  find  themselves  opposed  and 
thwarted  in  their  aims  by  minds  more  guided  by  legal  acumen 


EMOTIONAL   INSANITY.  233 

than  enlightened  by  the  scientific  status  of  the  questions  involved. 
Hence  the  breach  is  always  widening.  The  non-professional 
observer  of  the  contest  from  day  to  day  grows  more  sceptical, 
humanity  suffers,  and  the  discoveries  of  science  are  rendered  less 
available. 

We  have  already  referred  to  the  question  of  motive,  but  in  this 
particular  connection  a  few  more  remarks  may  be  added,  in  view 
of  the  importance  of  this  subject. 

AVhen  a  son  kills  his  father,  not  influenced  by  passion,  the  desire 
of  inheritance,  or  any  other  discoverable  cause,  a  strong  suspicion 
and  presumption  of  insanity  will  exist.  When  a  mother  de- 
stroys her  children  to  send  them  to  heaven,  the  same  doubt  of 
her  sanity  will  suggest  itself.  But,  gentlemen,  you  must  be  made 
aware  that  the  insane  are  influenced  by  the  ordinary  motives  of 
human  action  equally  with  persons  of  incontestable  sanity. 

If  you  visit  an  asylum  and  strike  one  of  the  patients,  he  will 
resist  your  violence  and  strike  back  ;  if  your  bearing  be  insulting, 
it  will  immediately  provoke  resentment.  In  the  ordinary  manage- 
ment and  discipline  of  institutions  for  the  insane  these  facts  are 
recognized,  and  the  entire  moral  treatment  is  thereby  influenced. 
They  are  therefore  punished  or  rewarded  in  a  paternal  manner 
when  the  necessities  of  their  case  demand  such  a  recourse,  other- 
wise the  rules  and  moral  discipline  which  form  the  most  important 
factors  in  promoting  their  restoration  would  be  without  success. 
Hence  the  maxim  never  to  be  lost  sight  of  in  dealing  with  the 
insane  consists  in  "  kindness  and  firmness,"  inasmuch  as  they  allow 
themselves  to  be  swayed  by  motives  like  other  people. 

Then,  again,  there  are  sane  people  the  interpretation  of  whose 
motives  is  but  too  often  an  inexplicable  mystery,  and  we  should 
have  to  plunge  very  deep  into  the  labyrinths  of  the  human  heart, 
into  the  innermost  recesses  of  the  soul,  to  be  always  successful  in 
our  eiforts  in  this  direction.  "  It  is  assumed  or  implied,"  says 
Dr.  Taylor,  with  great  justice,  "that  sane  men  never  commit  a 
crime  without  an  apparent  motive,  or  one  of  delusive  nature  only 
in  the  perpetration  of  a  criminal  act.  If  these  positions  were  true, 
it  would  be  very  easy  to  distinguish  a  sane  from  an  insane  criminal ; 
but  the  rule  wholly  fails  in  practice.  In  the  first  place,  non-dis- 
covery is  here  taken  as  a  proof  of  the  non-existence  of  a  motive ; 
while  it  is  undoubted  that  motives  may  exist  for  many  atrocious 


234  DISEASES   OP   THE   NEEYOUS   SYSTEM. 

criminal  acts  without  our  being  able  to  discover  tbem,  a  fact 
proved,  by  the  numerous  recorded  confessions  of  criminals  before 
execution^  in  cases  of  which,  until  these  confessions  were  made, 
no  motive  for  the  perpetration  of  the  crime  had  appeared  to  the 
acutest  minds."* 

Should  lunatics  be  hanged  ?  It  seems  hardly  necessary  in 
this  enlightened  age  to  discuss  such  a  question,  yet  the  subject 
is  occasionally  re-agitated,  notwithstanding  its  senseless  barbarit}^. 
Some  hold  that,  as  lunatics  are  dangerous,  expensive,  and  of  no 
possible  benefit  to  the  community,  pro  bono  publico  they  should 
be  hanged  as  soon  as  they  perpetrate  a  crime.  The  atrocious  in- 
humanity of  such  a  sentiment  is  as  disgraceful  as  it  is  brutal. 

Incarceration  of  the  insane  in  asylums  cannot  ward  off  the  same 
fate  from  others.  Example  can  exert  no  influence  in  the  pre- 
vention of  disease.  Forbes  Winslow,  commenting  on  this  subject, 
maintains  that  we  might  as  well  insist  upon  inflicting  capital  pun- 
ishment upon  epileptics  because  of  their  misfortune.  But  would  this 
prevent  the  development  of  epilepsy  in  a  single  individual  ? 

As  regards  the  plea  of  insanity  Lord  Hale's  views  were  ex- 
treme. He  held  that  "  there  must  be  defect  of  the  understanding, 
unequivocal  and  plain." 

Lord  Coke  held  "  that  whoever  by  sickness,  grief,  or  other  acci- 
dent wholly  loses  his  memory  and  understanding'^  is  non  compos 
mentis. 

Lord  Chief  Justice  Mansfield,  in  the  trial  of  Bellingham,  charged 
that  "  the  single  question  was  whether,  at  the  time  this  act  was 
committed,  he  jaossessed  a  sufficient  degree  of  understanding  to 
distinguish  good  from  evil,  right  from  wrong,  and  whether  murder 
was  a  crime  not  only  against  the  laws  of  God,  but  the  law  of  his 
country." 

Lord  Erskine  considers  "  delusion  where  there  is  no  frenz}^"  to 
be  the  true  character  of  insanity.  "  Viewed,  however,  as  a  princi- 
ple of  law,  the  delusion  and  act  should  be  connected."  Delusion  we 
admit  to  be  strong  presumptive  proof  of  insanity,  and  is  insanity 
in  almost  ninety-nine  cases  out  of  one  hundred.  "  Delusion  excep- 
tionally," says  Winslow,  "  may  be  present  and  not  be  incompatible 
with  sanity."     If  we  take  delusion  as  a  criterion,  we  are  liable  to 

*  Wharton  and  Stille's  Medical  Jurisprudence. 


EMOTIONAL   INSANITY.  235 

ignore  some  very  dangerous  forms  of  insanity,  because  there  are 
many  serious  manifestations  of  the  insane  temperament,  as  well  as 
many  affective  forms  of  insanity,  which  will  attract  our  attention 
only  through  actions  following  the  irresistible  impulse  of  distorted 
feelings.  Delusions,  therefore,  cannot  be  correctly  considered  a 
criterion  of  insanity,  since  it  may  indubitably  exist  without  their 
presence.  This  is  a  very  important  fact,  with  which  you  should 
be  acquainted,  because  for  a  long  time  in  England,  as  well  as  in 
America,  delusion  was  always  considered  a  sine  qua  non  of  insanity ; 
and  even  to-day  many  prejudiced  lawyers  consider  that  its  absence 
entirely  invalidates  the  plea  of  insanity,  and  many  very  important 
judicial  decisions,  involving  property,  and  even  life,  were  erro- 
neously based  upon  this  principle.  To-day  the  old  doctrine  is 
rejected,  almost  entirely,  by  the  best  authorities,  and  the  new  one 
is  receiving  no  little  legal  sanction  ;  and  if  you  adhere  to  obsolete 
ideas  you  will  necessarily  aid  in  impeding  psychological  progress. 

According  to  the  64th  article  of  the  French  penal  code,  "  II 
n'y  a  ni  crime  ni  delit  lorsque  le  prevenu  etait  en  4tat  de  d6mence 
au  temps  de  Faction." 

Forbes  Winslow,  in  commenting  upon  the  above  opinions, 
states,  "  I  am  disposed  to  express  my  complete  concurrence  in  the 
views  of  Dr.  Haslam  on  this  point,  that  '  it  is  not  the  province  of 
medical  writers  to  pronounce  an  opinion  as  to  the  prisoner's  capa- 
bility of  distinguishing  right  from  wrong.  It  is  the  duty  of  the 
medical  man,  when  called  upon  to  give  evidence  in  the  court  of 
law,  to  state  whether  he  considers  insanity  to  be  present  in  any 
given  case,  not  to  ascertain  the  quantity  of  reason'*  which  the 
person  imputed  to  be  insane  may  or  may  not  possess.'  " 

"  If  it  should  be  presumed,"  says  Dr.  IIaslam,f  "  that  any  medi- 
cal practitioner  is  able  to  penetrate  into  the  recesses  of  a  lunatic's 
mind  at  the  moment  he  committed  the  outrage,  to  view  the  internal 
play  of  obtruding  thoughts  and  contending  motives,  and  to  depose 
that  he  knew  the  good  and  evil,  right  and  wrong,  he  was  about 
to  commit,  it  must  be  confessed  that  his  knowledge  is  beyond  the 
circuit  of  our  attainment.  It  is  sufficient  for  the  medical  prac- 
titioner to  know  that  such  a  person's  mind  is  deranged,  and  that 

*  Italics  my  own. 

I  Forbes  Winslow,  "  Plea  of  Insanity  in  Criminal  Cases." 


236  DISEASES   OF   THE   NERVOUS  SYSTEM. 

such  a  state  of  insanity  will  be  sufficient  to  account  for  tlie  irregu- 
larity of  his  actions,  and  that  in  a  sound  mind  the  same  conduct 
would  be  deemed  criminal.  If  violence  be  inflicted  by  such  a 
person  during  a  paroxysm  of  rage,  there  is  no  acuteness  of  meta- 
physical investigation  which  can  trace  the  succession  of  thoughts 
and  the  impulses  by  which  he  is  goaded  to  the  accomplishment 
of  his  purpose." 

I  am  sure,  gentlemen,  that  you  Avill  perceive  from  what  has 
been  insisted  upon  in  the  first  part  of  this  lecture  that  the  most 
dangerous  forms  of  insanity  are  those  in  which  neither  illusions, 
delusions,  hallucinations,  nor  perversions  of  the  intellect  generally, 
are  discoverable. 

As  regards  the  recognition  of  the  difference  between  right  and 
wrong,  it  is  now  an  indisputable  fact  that  nearly  all  the  insane 
make  the  distinction  without  difficulty. 

I  here  cite  from  Folsom  on  "  Mental  Diseases"  the  following 
opinions : 

"  Lord  Bramwell  once  said  that  '  insanity  is  strong  but  not 
conclusive  evidence  of  innocence ;'  and  Lord  Blackburn  has  stated 
that  '  the  jury  must  decide  in  each  individual  case  whether  the 
disease  of  the  mind,  or  the  criminal  will  was  the  cause  of  the  crime.' 
The  position  of  Sir  James  Stephen,  in  his  '  History  of  the  Criminal 
Laws  in  England,'  best  states  the  most  recent  views  of  irresponsi- 
bility,— namely,  that  '  no  act  is  a  crime  if  the  person  who  does  it 
is,  at  the  time  when  it  is  done,  prevented  either  by  defective  mental 
power  or  by  any  disease  affecting  his  mind  from  controlling  his 
own  conduct,  unless  the  loss  of  the  power  of  control  has  been 
produced  by  his  own  default.'  He  says  that  a  man  laboring  under 
such  a  defect  of  reason  that  he  does  not  know  that  he  is  doing 
what  is  wrong  may  be  defined  as  one  deprived,  by  disease  affecting 
the  mind,  of  the  power  of  passing  a  rational  judgment  on  the 
moral  character  of  the  act  which  he  meant  to  do.  There  are  per- 
sons too  insane  to  make  a  valid  will  by  virtue  of  a  single  delusion, 
whose  right  to  vote,  under  the  law  prohibiting  the  insane  from 
voting,  would  not  be  questioned.  Another  might  not  be  held 
responsible  for  crime,  and  still  make  a  contract  involving  the 
rights  of  others  besides  himself  that  would  hold  in  law," 

"  Bucknill's  recent  medico-legal  definition  of  insanity  is,  inca- 
pacitating weakness  or  derangement  of  mind  produced  by  disease ; 


EMOTIONAL   INSANITY.  237 

meaning,  in  criminal  cases,  inability  of  abstaining  from  the  criminal 
act,  which  would  be  expressed  by  Lord  Bramwell's  test,  '  Could 
he  help  it  ?'  Bucknill  suggests  as  an  amendment  to  the  law  of 
England  that  no  act  is  a  crime  if  the  person  who  does  it  is  at  the 
time  incapable  of  not  doing  it  by  reason  of  idiocy  or  of  disease 
affecting  the  mind."     (Folsom.) 

The  volitional  centres  are  invariably  affected  in  all  forms  of 
insanity.  Hence  in  every  judicial  charge  the  question  to  he  deter- 
mined is  as  to  whether  or  not  the  criminal  pleading  insanity,  while 
recognizing  the  difference  between  right  and  wrong,  is  able  or  unable 
to  control  his  action. 

Baillarger  states  that  the  essential  element  of  insanity  is  loss 
of  free  will. 

Ball,  of  Paris,  describes  an  insane  man  as  "  one  who  in  conse- 
quence of  a  profound  disturbance  of  the  mental  faculties  has  lost 
more  or  less  completely  his  free  will  and  has  ceased  thereby  to  be 
responsible  for  his  actions." 

It  would  be  as  rational  to  punish  a  school-boy  whose  antics  and 
grimaces,  the  result  of  chorea,  are  a  source  of  laughter  and  dis- 
traction to  his  school-mates,  as  to  inflict  punishment  upon  the 
insane  criminal,  who,  knowing  the  difference  between  right  and 
wrong,  has  it  not  in  his  power  to  execute  that  which  his  judgment 
dictates.  One  is  under  the  dominant  influence  of  "  insanity  of 
the  muscles,"  the  other  is  under  the  influence  of  insanity  of 
the  will.*-  To  punish  one  would  be  as  cruel  as  to  punish  the 
other. 

One  of  the  most  powerful  forces  which  can  affect  the  workings 
of  the  intellect  is  that  derived  from  the  presence  and  influence  of  in- 
sanity, which  weakens  and  prevents  and  even  in  many  cases  annihi- 
lates the  faculties  of  volition.  Without  the  exercise  of  the  regulating 
power  of  volition,  mental  convulsion  and  discordant,  incoordinated, 
and  automatic  actions  are  inevitable  with  blind,  instinctive,  and 
irresponsible  results.  No  moral  responsibility,  therefore,  can  exist 
where  insanity  subverts  the  directing  and  controlling  power  of  the 
will.  It  gives  me  pleasure  to  state  that  the  Supreme  Court  of  the 
United  States  in  a  recent  decision  maintains  that  the  presence  or 
absence  of  will-power,  in  the  plea  of  insanity,  is  the  question  upon 

*  Forbes  Winslow. 


238  DISEASES   OF   THE   NERVOUS   SYSTEM. 

which  the  existence  of  criminality  and  responsibility  exclusively 
depends. 

Insanity  as  an  extenuating  plea  in  cases  of  murder  requires  that 
the  previous  condition  of  the  individual's  life  should  be  investi- 
gated. Winslow  declares  "it  necessary  to  inquire  whether  the 
person  has  at  any  previous  period  of  his  life  manifested  any  signs 
of  mental  derangement ;  if  such  be  the  fact,  it  ought  to  constitute 
a  prima  facie  case  in  his  favor." 

Isolated  facts,  when  introduced  in  support  of  the  plea,  with  no 
exceptions,  in  my  opinion,  notwithstanding  the  weight  of  the  dis- 
tinguished authority  just  quoted,  should  be  valueless,  unless  the 
insanity  can  be  established  by  a  concurrence  of  indisputable  and 
conclusive  facts  resting  upon  the  broad  principles  of  medical 
diagnosis.  Upon  this  point  I  cannot  too  strongly  insist.  In 
order  to  facilitate  the  interpretation  of  cases  in  which  the  plea  of 
emotional  insanity  is  made.  Dr.  Pritchard  lays  down  the  follow- 
ing rules,  based  upon  the  conjoint  observations  of  Esquirol  and 
himself : 

1.  "  Acts  of  homicide  perpetrated  or  attempted  by  insane  per- 
sons have  generally  been  preceded  by  other  striking  peculiarities 
of  action,  noted  in  the  conduct  of  these  individuals,  often  by  a 
total  change  of  character. 

2.  "  The  same  individuals  have  been  discovered  in  many  in- 
stances to  have  attempted  suicide,  to  have  expressed  a  wish  for 
death  ;  sometimes  they  have  begged  to  be  executed  as  criminals. 

3.  "  These  acts  are  without  motive,  they  are  in  opposition  to 
the  known  influences  of  all  human  motives.  A  man  murders  his 
wife  and  children,  though  known  to  have  been  tenderly  attached 
to  them  ;  a  mother  destroys  her  infant. 

4.  "The  subsequent  conduct  of  the  unfortunate  individual  is 
generally  characteristic  of  his  state.  He  seeks  no  escape  or  flight, 
delivers  himself  up  to  justice,  acknowledges  the  crime  laid  to  his 
charge,  describes  the  state  of  mind  which  led  to  its  perpetration  ; 
or  he  remains  stupefied  and  overcome  by  a  horrible  consciousness 
of  having  been  the  asrent  in  an  atrocious  deed. 

5.  "  The  murderer  generally  has  accomplices  in  vice  and  crime  ; 
there  are  assignable  inducements  which  led  to  the  commission, 
motives  of  self-interest,  of  revenge,  displaying  wickedness  pre- 
meditated.    In  some  instances  the  acts  of  the  madman  are  pre- 


EMOTIONAL   INSANITY.  239 

meditated,  but  his  premeditation  is  peculiar  and  characteristic. 
There  is  also  a  presumption  of  insanity,  where  the  individual  has 
either  been  previously  insane,  or  affected  by  epilepsy."  * 

It  is  therefore  self-evident,  gentlemen,  from  all  that  has  been 
said,  that  while  insanity  in  general  is  "  a  reasoning  unreason"  yet 
in  the  emotional  or  affective  form  of  that  disease  we  must  ignore 
the  particular  morbid  manifestations  of  thought  as  expressed  in 
words,  and  confine  ourselves  to  the  study  of  the  actions  which 
portray  a  disordered  condition  of  feeling.  The  plea  of  emotional 
insanity,  we  have  ascertained,  far  from  being  one  of  a  trivial 
nature  and  easily  maintained,  as  popular  prejudice  might  induce 
you  to  believe,  is  of  an  intricate  and  complicated  character,  re- 
quiring for  its  establishment  a  thorough  knowledge  of  the  phi- 
losophy of  the  general  subject  of  insanity  and  no  ordinary  powers 
of  observation  and  analysis.  In  addition  to  this,  the  physician 
investigating  the  phenomena  of  emotional  insanity  should  possess 
earnestness,  perfect  candor,  and  an  unbiassed  mind.  Leaning  in 
one  direction  or  another  redounds  to  the  discredit  of  science  and 
the  still  further  degradation  of  a  most  legitimate  plea,  which,  if 
resting  upon  the  basis  of  a  careful  diagnosis,  is  sound  in  theory 
and  practice  and  of  great  service  in  a  philanthropic  point  of  view. 
When  abused,  as  it  is  but  too  often,  the  plea  can  result  only  in  the 
perversion  of  justice  and  in  professional  disgrace,  and  in  detri- 
mental effects  reaching  not  only  the  individual  but  also  society 
at  large. 

*  Forbes  "Winslow,  "  Plea  of  Insanity  in  Criminal  Cases." 


LECTUKE    XV. 

INSANITY — continued. — MELANCHOIilA. 

Phenomena — "  Concrete  Form  of  Misery" — Difference  between  Melancholia  and  Mania — 
Lypemania  and  Pantophobia — "  Furor  MelancJiolicua" — Hypochondriacal  Melancho- 
lia, Phenomena  of;  Case  of — Another  Form  of  Melancholia — Distention  and  Torpor 
of  Colon — Tendency  to  Suicide — Melancholia  Attonita — Folie  Circulaire,  or  "  Circular 
Insanity" — Paroxysmal  Violence  not  necessarily  an  Evidence  of  Insanity — Affective 
Form  rarely  absent — Moral  Treatment:  Evil  Effects  of  Delay,  Beneficial  Effects  of 
Asylum  Treatment — Medical  Treatment :  Opium,  Aloetic  Laxatives,  Tonics,  Alcoholic 
Stimulants,  Sulfonal  for  Insomnia,  Rhamnus  Frangula,  Phenacetin  and  Citrate  of 
Caffeine  in  Posterior  Cervical  Pains  of  Melancholia,  Repression  of  Menstruation. 

Gentlei^ien, — To-niglit  we  will  commence  the  consideration 
of  the  other  forms  of  insanity.  The  first  one  I  shall  speak  of, 
and  one  with  which  you  will  frequently  meet,  is  melancholia. 
Melancholia,  as  the  name  denotes,  is  characterized  by  great  mental 
depression,  excessive  grief,  and  painful  sadness,  and  owes  its  origin 
" to  the  usual  dual  cause"  as  M.  Allen  Starr  properly  observes, 
— viz.,  "physical  ill  health  and  mental  strain"  It  belongs,  for 
the  most  part,  to  the  affective  or  pathetic  variety  of  insanity,  as 
it  relates  more  to  the  feelings  of  the  individual  than  to  his 
intellect. 

The  first  phenomena  to  be  observed  are,  peculiar  mental  de- 
pression, vague  and  indefinable  oppression,  strange  and  inde- 
scribable sorrow.  There  is  a  state  of  gloom  which  the  patient 
cannot  shake  off,  '•  an  oppression  of  the  self,"  and  his  despond- 
ency is  to  himself  something  altogether  unaccountable ;  he  is  at  a 
loss  to  explain  why  he  is  so  sad,  or  why  he  experiences  this  vague 
and  indefinite  condition;  in  short,  he  is  entirely  overwhelmed 
and  completely  overburdened,  life  becomes  a  misery,  and  existence 
is  unendurable.  This  general  affective  dejection  may  constitute 
the  entire  morbid  state,  no  delusions  existing,  the  feelings  only 
being  perverted  without  any  implication  of  the  intellect.  Delu- 
sions produce  a  form  of  insanity  in  which  we  always  presuppose 
an  affectioD  of  the  intellect;  that  is  ideational  insanity.  As 
240 


MELANCHOLIA.  241 

Maudsley  says,  after  the  mental  depression  of  melancholia  has 
existed  for  some  time,  "a  concrete  form  of  misery"  is  produced; 
the  patient  seems  to  assume  some  fixed  and  settled  idea,  or  de- 
velops a  terrible,  all-absorbing  delusion.  This  concreteness  is  in- 
dicated by  delusion,  and  suggesting,  as  it  does,  a  hypothetical  cause 
for  the  overpowering  anxiety  of  the  mind,  far  from  increasing  the 
grief  or  depression,  seems  generally  to  afford  relief.  This  delu- 
sion, however,  bears  no  adequate  relation  to  the  intensity  of  the 
melancholia.  In  some  persons  it  appears  as  a  very  trivial  matter, 
in  others  it  is  "  expressive  of  some  great  fear  or  suffering."  We 
find  some  melancholic  patients  laboring  under  the  belief  that  they 
have  comixiitted  some  grave  offence,  or  that  they  are  guilty  of 
"  the  unpardonable  sin."  They  imagine  that  they  are  suffering 
the  torments  of  the  damned,  and  experience  these  tortures  for  some 
trivial  delinquency,  which  ideas  are  absurd,  of  course,  but  greatly 
exaggerate  their  distress.  In  melancholia,  which  strictly  pertains 
to  the  affective  variety  of  insanity,  the  morbid  manifestations  are 
mainly  evinced  in  the  actions  of  the  patient,  Avhile  in  mania,  the 
intellect  being  affected,  the  disturbances  are  chiefly  exhibited  in 
the  words,  as  expressive  of  thoughts. 

Melancholia,  as  met  in  general  practice,  at  the  bedside,  or  in  the 
hospitals,  is  capable  of  being  separated  into  two  original  groups, — 
lypemania  and  pantophobia.  Lypemania  consists  of  melancholia 
that  is  always  attended  by  delusions.  Pantophobia  refers  to  a 
condition  of  the  patient  which  is  characterized  by  a  constant 
dread  and  fear  of  everything,  without  any  definite  cause  for  ap- 
prehension. The  latter  is  melancholia  without  "  concrete  form." 
Remember  that  this  division  is  made  by  Maudsley  simply  for 
practical  purposes.  I  have  already  told  you  that  there  are  two 
grand  primary  divisions  of  insanity, — the  affective  form,  relating 
to  morbid  feelings,  and  the  ideational,  relating  to  perverted  intel- 
lection. All  cerebral  disorders  resulting  in  insanity  come  under 
one  or  the  other,  or  under  both,  of  these  forms.  This  being  the  case, 
it  follows  that  just  as  we  have  melancholia  without  intellectual 
insanity,  we  sometimes  have  mania  with  disordered  actions  only, 
and  of  purely  affective  nature. 

When  mania  exists,  it  is  almost  invariably  in  the  form  of  intel- 
lectual insanity ;  still,  the  precursor}^  manifestations  are  emotional, 
and  we  have  acts  expressive  of  deranged  sentiments,  affections, 

16 


242  DISEASES   OF   THE   NERVOUS   SYSTEM. 

habits,  etc.,  prior  to  other  developments.  In  mania,  therefore, 
when  affective  in  character,  the  perverted  feelings  are  preter- 
naturally  excited, — in  contradistinction  to  melancholia,  in  which 
they  are  depressed.  Therefore,  when  the  insane  feelings  are  excited, 
there  is  an  affective  mania  ;  when  they  are  depressed,  there  is  an 
affective  melancholia.  If  now  in  affective  melancholia  delusions 
supervene,  the  intellectual  powers  becoming  impaired,  the  faculty 
of  reasoning  is  involved,  the  conversation  is  more  or  less  irrational, 
and  then  intellectual  insanity  has  appeared  and  complicated  the 
case. 

The  first  phenomena  of  melancholia  refer  to  disturbed  feelings, 
through  grief,  sadness,  despondency,  etc.,  without  any  intellectual 
derangements.  Of  course  the  patient  is  not,  as  yet,  ideationally 
insane  ;  but  delusions  may  sooner  or  later  complicate  the  case,  and 
we  then  have  ideational  insanity,  and  the  patient's  abnormal  con- 
dition will  be  manifested  alike  in  words  and  in  actions. 

Another  subdivision  of  melancholia  is  the  hypochondriacal.  In 
this  form  we  find  the  individual  studying,  criticising,  analyzing, 
examining,  and  investigating  his  own  real  or  supposed  bodily  ail- 
ments. He  imagines  himself  the  victim  of  some  disease  ;  perhaps 
he  has  a  "  fluttering  of  the  heart,  a  film  before  his  eyes,"  etc.,  and 
all  sorts  of  indescribable  troubles  annoy  him.  He  watches  these 
hypothetical  symptoms  and  interprets  them  in  his  own  way,  and, 
when  consulting  a  physician,  will  often  give  explanations  of  his 
disease  which  are  really  remarkable.  It  occurs  in  many  instances 
that  a  melancholic  patient  may  be  only  slightly  hypochondriacal, 
and  yet  be  unable  to  attend  to  his  business  or  pursue  the  ordinary 
vocations  of  life.  Of  course  this  constant,  self-absorbing  pre- 
occupation becomes  a  source  of  disease,  and  results  disastrously, 
by  inducing  certain  changes  in  one  or  more  organs.  The  inces- 
sant concentration  of  the  mind  on  the  feelings  develops  delusions, 
and,  acting  under  the  influence  of  such  perverted  ideas,  the  patient 
may  be  led  to  the  commission  of  rash  actions,  with  terrible  conse- 
quences. Whence  do  our  actions  spring?  Whence  our  impulses? 
They  originate  from  the  feelings  ;  hence  the  perverted  feelings, 
stimulated  by  a  morbid  influence,  will  sometimes  induce  a  patient 
to  commit  suddenly  some  terrible  crime,  and  this  may  occasionally 
happen  even  in  some  form  of  hypochondriasis.  It  has  occurred, 
as  related  by  Maudsley,  that  a  patient  cut  open  his  abdomen  with 


MELANCHOLIA.  243 

a  piece  of  glass,  penetrating  the  intestine,  simply  "to  let  out 
the  gas." 

Now,  when  the  feelings  are  thus  perverted  so  as  to  constitute 
disease,  whether  slight  or  intense,  it  gives  the  physician  great 
annoyance  ;  and  many  hypochondriacs  out  of  asylums  will  come 
and  torture  you  by  a  detailed  account  of  their  troubles.  The  face 
will  be  pinched  and  anxious,  the  story  related  you  will  perhaps 
have  heard  a  hundred  times  and  know  by  heart,  and  yet  you  must 
patiently  listen.  To  treat  such  people  is,  indeed,  a  task,  though 
it  is  at  times  exceedingly  interesting  to  observe  their  peculiarities. 
A  short  time  ago  I  had  under  treatment  a  hypochondriacal  gentle- 
man, who  stated  that  he  was  suifering  from  muscular  rheumatism 
to  such  an  extent  that  all  locomotion  was  impeded.  This  pain 
had  resisted  iodide  of  potassium,  salicylate  of  sodium,  and  all 
other  treatment.  The  other  evening  I  saw  him ;  he  recollected 
that  he  wanted  to  go  to  a  certain  place  of  amusement  that  very 
night,  which  inclination  so  absorbed  his  thoughts  that  he  overcame 
his  morbid  feelings,  jumped  up  suddenly,  walked  oif  briskly,  and 
was  cured,  until,  his  interest  being  no  longer  excited  by  extraneous 
matters,  the  old  trouble  returned,  because  his  thoughts  reverted 
to  the  same  morbid  channels.  All  cases  of  insanity  are  not  sent 
to  the  asylum  for  treatment.  Some  wealthy  families  will  often 
seriously  object  to,  and  strenuously  oppose,  a  removal  of  one  of 
their  members,  their  station  in  life  enabling  them  to  furnish  all 
possible  conveniences  and  comforts  to  the  patient  at  home. 

There  is  another  form  of  melancholia,  which  you  may  meet 
with  in  the  asylums  as  well  as  in  private  practice,  and  which  you 
should  be  able  to  recognize.  I  refer  to  melancholia  with  excite- 
ment, or  '^ Juror  melancholicus/^  which  is  sometimes  not  readily 
distinguished  from  mania.  Delusions  will  appear,  and  the  patient 
become  very  prone  to  violence ;  a  dangerous  homicidal  propensity 
will  be  developed,  and  intense  mental  anguish  may  culminate  in 
suicide.  This  morbid  tendency  to  the  consummation  of  some 
terrible  act  is  engendered  by  the  desire  to  relieve  the  crushing 
depression.  I  remember  a  case  in  an  asylum,  where  such  a  patient, 
who  had  previously  been  considered  harmless,  actually  knocked 
a  man  down  and  beat  his  brains  out  with  a  chair  before  assistance 
could  be  obtained.  When  asked  by  the  coroner  his  reason  for 
committing  this  crime,  and  if  he  had  any  spite  against  his  victim, 


244  DISEASES   OF   THE   NERVOUS   SYSTEM. 

or  had  any  previous  quarrel  with  him,  he  simply  answered,  no ; 
that,  on  the  contrary,  they  had  always  been  good  friends,  and 
it  Avas  only  the  pent-up  feeling,  the  excruciating  mental  torture, 
which  he  by  some  act  desired  to  relieve,  that  caused  him  to  commit 
this  deed  of  blood.  Such  being  the  possible  consequences  of 
perverted  emotions,  you  will  readily  understand  why  this  aifective 
form  of  insanity  is  so  tnuch  to  be  dreaded. 

Another  danger  in  melancholia,  and  one  against  which  you 
must  always  be  upon  your  guard,  is  a  tendency  to  suicide.  This 
impulse  has  to  be  thwarted ;  and  the  actions  of  all  melancholic 
patients  are  to  be  closely  watched  on  this  account,  as  the  in- 
tensity of  their  mental  suffering  is  sometimes  so  great  that  they 
frequently  attempt,  and  but  too  often  succeed  in  accomplishing, 
their  own  destruction.  They  resort  to  cunning  artifices  of  every 
description  for  the  accomplishment  of  their  purpose,  picking  up 
pins  and  needles  from  the  floor,  and  concealing  all  sorts  of  objects, 
with  which  at  night  they  will  attempt  to  destroy  themselves.  I 
have  known  them  to  secrete  a  table-knife,  to  use  at  the  first  oppor- 
tunity when  unobserved ;  and  in  my  own  experience  I  recollect 
a  patient  who  cut  his  throat  from  ear  to  ear  with  a  knife  which 
he  had  slyly  abstracted  from  the  dinner-table  and  sharpened 
on  the  window-sill.  Indeed,  the  more  closely  they  are  watched, 
especially  if  they  suspect  it,  the  more  persistent  are  they  in  their 
efforts  at  concealment  and  deception.  Hence  a  sleepless  vigilance 
alone  will  be  successful  in  frustrating  their  destructive  propensi- 
ties. It  was  formerly  taught  that  suicide  was  one  of  the  dreaded 
terminations  of  melancholia,  but  it  is  now  generally  admitted 
that  it  is  a  symptom  of  the  disease,  and  that  the  person  should 
never  be  left  one  minute  alone. 

"  So  far  from  the  morbid  impulse  or  act  constituting  the  insanity, 
it  is  but  the  outward  and  visible  sign  or  expression  of  a  profound 
affective  derangement,  the  tendency  of  which  is  to  manifest  itself, 
not,  like  ideational  insanity,  in  words,  but  in  acts,  and  which  for 
this  very  reason  is  much  more  dangerous  than  ideational  insanity. 
So  far  from  the  disease  being  simply  a  homicidal  or  suicidal  in- 
sanity, it  is  truly  an  affective  insanity,  one  symptom  of  which  is 
homicidal  or  suicidal  impulse :  the  delusion,  when  there  is  one, 
and  the  homicidal  act  are  both  symptoms  of  the  disease ;  and  the 
morbid  manifestation  of  one  may  be  as  little  under  control  as  of 


MELANCHOLIA.  245 

the  other,  or  as  the  suddenly  arising  hallucination.  In  the  one 
case  the  patient  is  the  victim  of  a  morbid  idea  ;  in  the  other,  of  a 
morbid  movement ;  in  both  cases,  of  a  convulsion  more  or  less 
co-ordinated.  Where  the  disease  is  less  acute,  it  is  the  feeling  of 
this  aSective  perversion  that  sometimes  drives  the  melancholic  to 
commit  murder  in  order  to  be  hanged,  or  impels  a  mother  to 
murder  her  children  in  order  to  send  them  from  misery  on  earth 
to  happiness  in  heaven.  It  admits  of  no  question  whatsoever,  and 
should  therefore  be  borne  clearly  in  mind,  that  the  calmest  melan- 
cholic is  liable  to  periodical  unaccountable  exacerbations  of  dis- 
ease, during  the  paroxysms  of  which  he  may  perpetrate  violence 
against  himself  or  others  ;  a  wonderful  relief,  and  even  an  apparent 
sanity,  with  endeavor  to  escape  penal  consequences,  sometimes  fol- 
lowing the  accomplishment  of  the  act."     (Maudsley.) 

Another  form  of  melancholia,  and  one  which  might  be  con- 
founded with  dementia,  is  melancholia  attonita,  or  melancholia 
with  stupor.  Life  in  such  patients  seems  to  be  pm-ely  vegetative ; 
they  will  take  no  food,  refusing  even  to  swallow  it  when  it  is 
placed  in  their  mouths.  At  times  they  will  resist  all  efforts  to  in- 
troduce aliment  into  their  stomachs,  from  fear  of  being  poisoned, 
imao;inino;  that  some  relative  or  friend  wishes  to  kill  them.  The 
peculiarity  of  this  variety  is  that  the  patient  is  in  a  seemingly 
cataleptic  condition, — a  quasi  stupor  or  somnolent  inertia, — and  on 
account  of  his  immobility  forcibly  reminds  you  of  a  statue.  Once 
having  assumed  a  position,  the  patient  will  maintain  it  for  hours, 
perhaps  for  a  whole  day,  or  until  utterly  exhausted.  There  is  a 
striking  inanimation,  the  organic  functions  appear  almost  to  be 
held  in  abeyance,  the  animal  actions  are  suspended,  and  the  face 
is  a  blank,  without  the  slightest  expression  or  play  of  emotion. 
There  is  no  consciousness  of  time,  locality,  or  personal  identity ; 
the  patient  has  not  the  least  idea  of  his  surroundings,  sometimes 
involuntarily  swallowing  anything  placed  upon  his  tongue,  and  at 
other  times  it  will  be  impossible  to  make  him  eat,  until  you  at  last 
resort  to  the  stomach-pump,  introducing  food  mechanically.  At 
times  the  patient  will  temporarily  revive,  like  a  person  awaken- 
ing from  a  sound  and  protracted  slumber,  during  which  he  has 
apparently  been  dreaming,  and  will  make  inquiries  which  un- 
doubtedly point  to  previous  unconsciousness.  His  mind  has  been 
engrossed  in  one  terrible   delusion,  which  wholly  absorbed   his 


246  DISEASES   OF   THE   NERVOUS   SYSTEM. 

faculties ;  but  one  feeling,  one  idea,  has  prevailed,  in  which  his 
whole  being  has  been  concentrated,  and  since,  as  Dr.  Maudsley 
remarks,  to  be  wrapped  up  in  one  sensation  would  be  equivalent 
to  the  possession  of  none,  we  can  understand  the  profundity  of 
the  patient's  lethargy.  This  form  of  melancholia  is  really  pain- 
ful to  witness,  and  the  immobile  and  cadaverous  appearance  of  its 
victims  is  well  calculated  to  arouse  sympathy. 

Still  another  form  of  insanity  to  be  considered  is  what  is  termed 
by  the  French  folie  drculaire,  or  "  circular  insanity/'  In  this 
form  there  is  a  certain  alternation  in  the  manifestations  from 
melancholia  to  mania,  and  it  may  be  a  difficult  matter  to  differ- 
entiate between  the  two  diseases.  At  one  time  there  may  be  an 
exacerbation  characteristic  of  mania,  followed  by  a  period  of  men- 
tal depression.  I  have  seen  this  type  of  insanity  develop  itself 
towards  the  termination  of  protracted  cases  of  melancholia,  and 
in  a  case  of  five  years'  duration  of  the  latter  affection,  now,  strange 
to  relate,  convalescent,  folie  drculaire  was  the  immediate  precursor 
of  the  present  favorable  condition.  The  case  to  which  I  refer 
was  that  of  a  distinguished  divine,  and  was  the  most  profound 
I  have  ever  witnessed,  being  for  eighteen  months,  in  the  earlier 
periods,  melancholia  attonita.  Folie  drculaire,  however,  very  rarely 
follows  this  satisfactory  course,  as  in  many  cases  of  inveterate  and 
incurable  insanity  it  will  be  present. 

Perhaps  it  would  be  well  for  me  to  caution  you  against  sup- 
posing that  acts  of  paroxysmal  violence  necessarily  constitute  a 
feature  of  affective  insanity.  This  would  be  an  erroneous  conclu- 
sion, as  such  explosions  are  purely  symptomatic,  really  forming 
but  a  single  feature  of  the  malady,  and  in  some  cases  are  entirely 
absent :  just  as  in  ideational  insanity  we  do  not  necessarily  find 
delusions,  though  they  are  generally  present,  so  in  some  cases  of 
affective  disorder  murderous  and  suicidal  and  other  morbid  pro- 
pensities may  not  be  manifested.  The  old  subdivision  of  certain 
forms  of  insanity  into  pyromania,  erotomania,  suicidal  and  homi- 
cidal mania,  etc.,  was  quite  unfortunate,  and  calculated  to  lead  to 
erroneous  conclusions  :  we  now  know  that  the  propensities  con- 
stituting those  states  are  only  symptoms  or  outcroppings  common 
to  many,  and  hence  not  in  the  least  peculiar  to  any  special  form 
of  insanity.  As  I  have  said  in  previous  lectures,  the  most  dan- 
gerous forms  of  insanity  may  and  often  do  exist  without  delusion ; 


MELANCHOLIA.  247 

SO  also  these  last-mentioned  conditions  are  often  entirely  absent. 
Madmen  are  frequently  able  to  regulate  their  conversation  perfectly, 
speak  coherently,  and  even  astonish  you  with  the  brilliancy  of 
their  thoughts,  but  they  cannot  control  their  actions ;  hence  the 
affective  form  is  rarely  absent,  but  generally  pervades  all  the 
forms  and  varieties  of  insanity. 

To  repeat :  in  insanity  the  affective  type  is  almost  always  at 
the  bottom  of  the  difficulty,  developing  perverted  emotions  and 
change  of  habits.  This  state  may  be  very  dangerous  without  any 
evidence  of  intellectual  disorder.  In  short,  it  usually  complicates 
all  varieties  of  insanity,  preceding,  accompanying,  or  following 
them,  thereby  greatly  influencing  their  course  and  profoundly 
modifying  their  manifestations.  These  are  very  important  facts, 
and  after  you  understand  them  a  great  part  of  the  subject  of 
insanity  will  become  clearer  to  your  minds. 

It  is  well  to  remember  that  the  moral  treatment  is  the  most 
essential  of  all  the  influences  requisite  in  the  management  of  this 
form  of  insanity.  The  moral  treatment  is  indispensable,  because 
perversion  of  sentiment  is  the  fundamental  condition  of  the  dis- 
ease. In  what  does  this  treatment  consist  ?  In  isolation,  seclusion, 
firmness  combined  with  kindness,  and  discipline  of  mind  and 
body.  I  have  already  told  you  that  when  a  person  is  insane  he 
is  no  longer  in  harmony  with  his  social  relations ;  there  is  some- 
thing out  of  gear,  and  he  may  become  a  source  of  danger  to  him- 
self and  to  others.  He  should,  therefore,  be  isolated,  and  treated 
by  those  who  understand  his  affection.  Metaphorically  speaking, 
the  loose  screw  should  be  accurately  adjusted,  and  the  machinery 
of  the  brain  be  oiled  and  reconstructed,  that  future  harmony  may 
prevail.  As  general  practitioners  it  is  your  first  duty  to  know 
this,  and  I  cannot  too  persistently  dwell  upon  it.  Many  an 
unfortunate  being,  through  neglect,  injustice,  or  ignorance,  has 
been  doomed  to  the  miseries  of  chronic  insanity,  compared  to 
which  all  other  sufferings  are  small,  and  the  agony  of  death  itself 
infinitely  preferable.  Yes,  death  is  a  thousand  times  more  de- 
sirable than  a  life  embittered  by  chronic  insanity  and  rendered 
desperate  and  horrible  by  the  perpetuity  of  its  wretchedness.  If 
this  practical  knowledge  were  the  only  benefit  you  have  derived 
from  these  lectures,  you  would  have  gained  much,  and  would  have 
acquired  information  which,  though  apparently  of  little  value,  is 


248  DISEASES   OF  THE  NERVOUS  SYSTEM. 

very  important  in  its  bearings  from  a  humane  point  of  view. 
When  the  patient,  consequently,  is  in  the  inceptive  stages  and 
the  disease  is  still  acute,  he  should  be  immediately  treated  or  sent 
to  an  asylum,  in  order  to  prevent  the  occurrence  of  hopeless  mis- 
chief. Why  is  it  that  the  number  of  inmates  of  county  and  State 
asylums  is  constantly  swelling  ?  Is  it  not  due  to  the  neglect  in 
this  regard  of  physicians,  or  to  unfortunate  legislation  and  the 
endless  amount  of  "  red  tape,"  by  which  the  destitute  are  left 
without  proper  treatment  until  the  disease  is  no  longer  acute,  but 
chronic, — its  intractability  being  in  exact  relation  to  its  dura- 
tion ?  By  this  time  the  patient  has  become  not  only  a  permanent 
burden  to  his  family  but  also  a  life-long  curse  to  himself,  and  the 
asylum  has  finally  to  open  its  doors  for  him  to  enter,  never  again, 
perhaps,  for  him  to  go  out.  Begin  your  treatment  early,  therefore, 
remembering  that  when  three  months  have  passed  insanity  ceases 
to  be  acute,  and  that  success  depends  upon  immediate  and  energetic 
treatment.  I  may  here  state  my  thorough  conviction  that  some 
cases  of  melancholia  may  recover  without  being  sent  to  an  asylum ; 
but  this  is  exceptional,  and  does  not  invalidate  the  rule.  Patients 
may  sometimes  be  effectively  treated  at  their  homes,  but  not  usually ; 
for,  while  a  rich  man  may  command  a  comfortable  residence  and 
faithful  attendants,  and  may  secure  more  eminent  physicians  to 
treat  him,  how  many  can  afford  these  expensive  conditions  of 
home  treatment  ?  and  is  not  the  number  of  the  suffering  and 
poor  infinitely  greater?  Moreover,  even  under  the  best  home 
treatment,  from  the  inexperience  of  nurses,  suicide  will  but  too 
often  result. 

There  is  often  a  prejudice  against  sending  persons  to  lunatic 
asylums,  from  the  fear  that  their  sudden  removal  to  such  asso- 
ciations may  prove  pernicious.  On  the  contrary,  the  moral  effect 
is  often  excellent :  the  patient  recoils ;  there  is  a  beneficial  shock, 
which  occasions  him  to  enter  into  himself  and  reflect,  "  Why  am  I 
here,  in  the  company  of  persons  so  plainly  mad  ?"  This  causes 
an  introspection,  with  a  most  salutary  effect,  to  which  the  order 
and  discipline  of  the  place  are  distinctly  auxiliary.  The  moral 
measures  also  concur  in  teaching  the  patient  to  exercise  a  cer- 
tain amount  of  self-control  and  to  make  efforts  towards  recovery. 
You  may  exhaust  the  therapeutic  resources  of  the  pharmacopoeia, 
and,  if  the  patient  do  not  try  to  get  well,  he  will  not  improve ; 


MELANCHOLIA.  249 

and  it  is  this  desire  of  restoration  for  which  I  look  as  the  first 
auspicious  sign  of  dawning  reason.  If  the  patient  evince  no 
energy,  he  will  not  get  well ;  but  if  he  try  to  disperse  the  mental 
mist  which  surrounds  him,  he  will  frequently  progress  favorably, 
and  his  endeavors  will  to  a  great  extent  be  advanced  by  the 
moral  treatment  he  receives. 

The  subjacent  'pathological  condition,  I  fully  believe,  as  has 
long  been  taught,  is  cerebral  ancemia. 

TEEATMENT. 

The  insane  should  be  treated  like  children,  with  kindness  and 
firmness,  with  uniform  affection  and  courtesy  ;  but  the  necessary 
exactions  must  be  unswervingly  enforced,  and,  like  children,  they 
should  be  rewarded  for  their  good  behavior  and  rebuked  for  their 
disobedience.  They  often  will  do  better,  or  at  least,  like  children, 
will  try  to  do  better.  When  depressed,  you  should  encourage  them 
and  reliev^e  their  mental  anxiety,  and  when  unruly,  you  must  check 
them,  but  without  undue  severity.  This  is  far  more  important 
than  the  medical  treatment,  in  regard  to  which  I  must  say  that  I 
have  not  unbounded  faith.  One  thing  is  certain,  as  maintained  by 
Schroeder  van  der  Kolk,  that  melancholia  is  often  due  to  a  loaded 
colon,  accompanied  by  obstinate  constipation.  In  such  cases  an 
aloetic  laxative,  or  Rhamnus  frangula,  the  laxative  par  excellence, 
will  generally  relieve  the  constipation  and  cause  mental  cheerfulness 
to  reappear.  Since  the  publication  of  the  last  edition  of  these  lec- 
tures, in  which  I  condemned  the  use  of  opium,  I  have  returned 
wdth  more  confidence  to  this  classic  treatment  of  melancholia. 
Judiciously  handled,  it  produces  more  permanent  and  beneficial 
effects  than  any  other  remedy  with  which  we  are  acquainted. 

As  in  the  affective  variety  of  insanity  there  are  great  mental 
sorrow  and  physical  prostration,  alcoholic  stimulants  can  be  bene- 
ficially administered.  ISIelancholic  patients  bear  them  remarkably 
well,  and  to  an  extent  truly  astonishing.  According  to  Blandford, 
such  patients  should  receive  alcoholic  stimulants  at  every  meal, — 
either  rum,  brandy,  or  whiskey.  Of  course  there  is  a  medium  in 
everything,  and  so  in  the. administration  of  these  stimulants  you 
should  bear  in  mind  that  what  may  be  too  little  for  one  may  be 
too  much  for  another.  I  have  always  found  the  breath  the  best 
guide,  in  this  as  well  as  in  acute  and  febrile  diseases,  in  determining 


250  DISEASES   OF   THE   NERVOUS   SYSTEM. 

the  proper  regulation  of  the  remedy :  if  surcharged  with  alcoholic 
fumes,  all  the  alcohol  is  evidently  not  appropriated,  the  system 
is  surfeited,  and  its  supply  should  be  correspondingly  curtailed. 
Headache  of  the  incipient  stage,  and  the  "  posterior  cervical  pain" 
described  by  Landon  C.  Gray,  may  be  relieved  by  phenacetin. 
Headaches  and  neuralgias  dependent  upon  cerebral  ansemia  are 
rapidly  and  magically  alleviated  by  the  following : 

R   Phenacetin.,  gr.  x; 

Oaffein.  citrat.,  gr.  iii. 
M.  at  ft.  chart,  no.  i. 
S. — Take  in  one  dose. 

Conquer  the  insomnia  at  night  by  the  judicious  administration 
of  sulfonal  or  paraldehyde,  remove  as  far  as  you  can  all  causes 
of  the  disease,  give  tonics,  and,  by  a  liberal  administration  of  milk 
and  nitrogenized  food  in  a  liquid  and  concentrated  form,  seek  to 
maintain  the  forces  in  the  best  possible  condition  to  resist  the 
inroads  of  the  malady.  It  should  never  be  forgotten  that  mel- 
ancholic patients  but  too  frequently  refuse  food,  through  some 
delusion  or  otherwise.  My  experience  of  a  quarter  of  a  century 
in  treating  the  insane  makes  me  concur  with  Blandford,  that 
this  is  a  most  vital  matter,  and  very  often  if  twenty-four  or 
forty-eight  hours  are  allowed  to  elapse  without  forced  feeding  the 
patients  will  perish.  The  stomach-pump  or  nasal  tube  should 
be  resorted  to  immediately,  to  avert  such  disastrous  results. 

Melancholia  in  women  in  many  instances  arises  from,  and  is 
perpetuated  by,  menorrhagia  and  metrorrhagia.  In  some  very 
interesting  cases  of  this  nature  repression  of  menstruation  has 
proved  successful  in  my  hands.* 

*  "  Results  of  Eepression  of  Menstruation,"  by  E.  C.  Gehrung,  M.D., 
American  Gynaecological  Transactions,  1889. 


LECTURE    XVI. 

INSANITY  —  continued. — mania. — monomania    (paeanoia). — 

DEMENTIA. — MORAL  INSANITY. — IDIOCY. — IMBECILITY. 

Acute  Delirious  Mania  (" Typhomania"),  or  Delirium  Grave— Treatment — Mania:  its 
Characteristics,  Course,  Prognosis,  and  Treatment — Monomania  ("  Paranoia") — De- 
mentia, Acute  and  Chronic — Moral  Insanity  :  Diagnosis  of;  Illustrative  Case — Idiocy 
— Moral  Imbecility — "  Linear  Craniotomy  in  Microcephalia" — "  Katatonia" — Hys- 
terical Insanity — Transitory  Insanity — Alcoholic  Insanity — Insanity  and  Bright's 
Disease — Insanity  following  Influenza — Insanity  complicating  Heart-Disease. 

Gentlemen, — In  my  last  lecture  I  spoke  to  vou  about  melan- 
cholia ;  to-night  I  begin  with  the  discussion  of  a  different  variety 
of  insanity,  known  as  mania.  For  practical  purposes  we  divide 
mania  into  acute  delirious  mania,  acute  mania,  and  monomania. 

Acute  delirious  mania,  or  delirium  grave,  is  that  form  of  insanity 
in  which  maniacal  symptoms  exist  with  more  or  less  elevation  of 
temperature ;  in  other  words,  when  superadded  to  the  ordinary 
symptoms  of  mania  there  is  more  or  less  heat,  which  can  readily 
be  detected  by  the  thermometer.  This  acute  delirious  mania  might 
more  properly  be  called  "  typhomania,"  on  account  of  the  invariable 
existence  of  adynamic  symptoms,  but  too  often  proving  fatal.  The 
symptoms  are  typhoid  in  character :  the  pulse  is  rapid  and  fre- 
quent, the  tongue  dry,  and  asthenia  becomes  more  or  less  prominent. 
It  is  well  to  understand  this  condition,  as  it  requires  immediate  and 
appropriate  attention.  Indeed,  the  disease  often  runs  so  rapid  a 
course  that  there  may  not  be  sufficient  time  to  effect  the  removal 
of  the  patient  to  an  asylum.  It  is  a  matter  of  life  and  death,  and, 
unless  earnest  measures  are  resorted  to,  the  patient  rapidly  grows 
worse  and  sinks,  which  indeed  is  usually  the  case  in  spite  of  all 
our  efforts  to  the  contrary. 

In  acute  delirious  mania  there  is  an  active  delirium  accom- 
panying the  symptoms  of  mania  not  unlike  what  we  meet  with  in 
acute  febrile  diseases,  especially  in  typhoid  fever.  The  delirium 
which  is  so  prominent  a  symptom  in  certain  low  forms  of  fever 

251 


252  DISEASES   OF   THE   NERVOUS  SYSTEM. 

should  not  be  mistaken  for  that  of  the  disease  under  consideration, 
as  the  manifestations  of  the  latter  are  much  more  active,  and 
the  absence  of  enteric  complications  constitutes  a  marked  feature. 
Although  the  thermometer  may  run  up  to  105°  F.,  the  pulse  be  fre- 
quent and  rapid,  and  sordes  accumulate  upon  the  teeth,  if  on  your 
guard  you  can  nearly  always  make  a  correct  diagnosis. 

The  onset  of  the  disease  is  usually  violent  and  sudden,  and  it 
runs  its  course  in  a  short  time,  sometimes  lasting  three  or  four 
days,  at  other  times  a  week  or  longer.  The  aspect  of  the  patient, 
history  of  the  case,  and  peculiarities  of  the  delirium  will  enable 
you  to  distinguish  this  affection  from  delirium  tremens,  meningitis, 
or  ordinary  cases  of  mania.  The  presence  of  tremor,  peculiar 
visual  hallucinations,  and  good-natured  delirium  in  delirium 
tremens,  the  different  character  of  the  symptoms  in  meningitis, 
and  the  absence  of  fever  and  asthenic  symptoms  in  mania,  will 
enable  you  to  avoid  errors  of  diagnosis. 

Spitzka,  quoting  Jessen,  states,  "  In  one  of  Jessen's  patients 
ai:£esthesia  became  so  extreme  that  he  gnawed  off  the  ungual 
pbalanx  of  one  of  his  fingers.  That  author  claims  that  pem- 
pliigus-like  vesicles  appear  in  the  otherwise  apparently  healthy 
skin,  especially  of  the  dorsal  faces  of  the  hands  and  feet.  He 
believes  this  to  be  a  comparatively  constant  sign ;  it  was  absent  in 
two  out  of  the  five  cases  observed  by  the  wa-iter,  while  phlegmons 
and  spontaneous  gangrene  were  additionally  noticed  in  one  of 
the  cases  that  had  pemphigus.  Most  of  these  conditions  are  due 
to  the  vaso-motor  paresis  which  marks  this  period." 

Spitzka  says,  "  The  majority  of  the  patients  affected  with  grave 
delirium  die  in  the  delirious  period  after  an  illness  of  a  few  weeks ; 
in  those  who  do  not  die  at  this  period  the  excitement  continues 
unabated  for  four  or  five  weeks,  the  subsequent  symptoms  of 
stupor  increase,  and  the  history  closes  with  a  fatal  coma.  Com- 
plete recovery  never  occurs  ;'^'  in  rare  instances  the  patients  emerge 
from  this  severe  disorder  with  a  slight  mental  defect ;  in  others 
paretic  and  terminal  dementia  supervene." 

We  should  use  stimulants  freely,  give  nutritious,  supporting 
food,  and  by  all  means  induce  sleep,  always  absent  and  very 
difficult  to  secure.     Obstinate  insomnia  is  found  in  all  forms  of 

*  Italics  my  own. 


ACUTE   DELIRIOUS   MANIA.  253 

mania,  and  is  frequently  a  pertinacious  symptom.  Of  all  tlie  thera- 
peutic measures  used  to  promote  sleep  imder  such  circumstances,  I 
formerly  believed  that  the  most  efficient  was  the  hydrate  of  chloral. 
Of  course  it  should  be  administered  cautiously,  and  not  be  given 
in  such  large  doses  as  were  recommended  by  Sir  James  Y.  Simp- 
son ;  for,  although  chloral  is  an  invaluable  addition  to  the  phar- 
macopoeia, it  is  as  potent  for  evil  as  for  good,  and  care  as  well 
as  judgment  should  be  observed  in  its  use.  Sulfonal,  however, 
is  undoubtedly  preferable  to  chloral ;  I  regard  it  as  the  safest 
and  most  effective  hypnotic  with  which  we  are  armed. 

It  should  not  be  forgotten  that  we  must  maintain  the  patient's 
strength  by  good  and  nutritious  food  of  easy  digestion  and  assimi- 
lation, and  that  concentrated  liquid  aliment,  such  as  beef-tea,  milk, 
alcohol,  etc.,  is  indispensable. 

Very  often  persons  afflicted  with  acute  delirious  mania  become 
so  violent  that  we  are  at  a  loss  to  know  how  to  control  them. 
One  of  the  best  measures  to  this  end  is  to  reduce  the  high  tem- 
perature in  the  way  recommended  by  Blandford  and  Sheppard, 
— hy  the  wet  pack.  Dip  a  large  sheet  in  cold  water,  and  com- 
pletely envelop  the  patient  in  it.  After  it  has  been  on  for  an  hour 
or  an  hour  and  a  half,  the  patient  having  been  wrapped  in  numerous 
heavy  blankets,  so  as  to  induce  free  perspiration,  the  temperature 
will  be  found  lower,  and  the  active  delirium  relieved.  Of  course, 
care  must  be  taken  that  the  water  be  not  too  cold,  that  the  appli- 
cation be  not  continued  too  long,  nor  the  patient  exposed  to  cold 
afterwards.  Phenacetin,  antipyrine,  and  quinine  may  be  resorted 
to  as  antipyretics,  but  should  be  carefully  watched. 

Ordinary  mania,  such  as  you  will  generally  meet  with  in  asy- 
lums, as  well  as  in  private  practice,  may  sometimes  resemble 
"  acute  delirious  mania  y"  but  in  the  former  there  is  no  fever, 
neither  is  there  a  rapid  pulse  or  a  heated  sldn.  Ideational  in- 
sanity, generally  preceded  by  affective  insanity,  exists  in  both. 

Spitzka  remarks  in  this  connection,  "  The  morbid  anatomy  of 
this  disease  consists  in  an  intense  hypersemia  of  the  brain  and  me- 
ninges. This  is  constantly  found  in  patients  dying  in  the  excited 
period  of  the  disorder ;  in  those  who  die  in  the  stuporous  period  the 
hypersemia  is  sometimes  obliterated  by  a  collateral  cedema ;  but  in 
all  the  brain  appears  swollen,  the  cortical  ganglionic  elements  are 
granular  or  opaque,  stain  poorly,  and  their  periganglionic  spaces, 


254  DISEASES  or  the  nervous  system. 

like  the  adventitial  lymph-sheaths,  are  literally  crammed  with  the 
formal  elements  of  the  blood.  In  the  single  case  examined  -post 
mortem  by  the  writer  white  streaks  were  found  on  either  side  of  the 
larger  vessels  in  the  pia.  Microscopic  examination  showed  that 
they  were  due  to  an  accumulation  of  leucocytes,  whose  preponder- 
ance suggests  an  inflammatory  nature  of  the  lesion,  rather  than  the 
condition  of  venous  engorgement  claimed  by  Kraift-Ebing.  A 
most  positive  sign  of  inflammation  was  found  in  the  case  referred 
to  :  the  arterioles  were  surrounded  by  an  area  staining  in  carmine 
with  a  beautiful  pink  flush,  probably  the  expression  of  a  molecular 
infiltration,  while  layers  of  newly-formed  fibrin  were  found  in  and 
around  the  adventitia. 

"  That  grave  delirium  is  the  result  of  a  vaso-motor  overstrain 
analogous  to  that  supposed  to  exist  in  paretic  dementia  is  sup- 
ported by  the  etiology,  the  manner  of  origin,  and  the  somatic 
sequelae  of  this  disorder." 

MANIA. 

According  to  Clouston,  "  Acute  mania — the  '  raving  madness' 
of  the  older  authors — is  perhaps  the  type  of  all  insanity,  both 
in  the  popular  and  professional  mind.  Standing  thus,  and  being 
the  least  rational,  least  conscious,  most  noisy,  most  unmanage- 
able, and  sometimes  the  most  dangerous  variety  of  mental  disease, 
it  affected  the  conceptions  and  the  treatment  of  all  other  varie- 
ties in  a  most  unfavorable  way.  In  it  many  patients  had  no 
more  '  reasoning  power  than  a  wild  beast,'  and  all  persons  con- 
cluded to  be  insane  (the  conception  of  insanity  was  then  a  much 
narrower  one,  embracing  much  fewer  j)ersons)  were  accordingly 
treated  by  manacles  and  chains,  stripes  and  darkness.  Small  com- 
passion was  felt  for  them,  few  laws  protected  them,  little  medical 
skill  or  study  was  exercised  in  their  behalf,  for  they  were  reckoned 
beyond  the  pale  of  ordinary  humanity.  Even  in  Esquirol's  time, 
at  the  beginning  of  this  century,  such  patients  are  pictured  in  wild 
contortion  and  fury  of  look  and  action,  and  are  represented  heavily 
bound  even  in  his  illustrations.  Yet  this  is  a  type  of  disease  that 
is  nowadays  not  at  all  so  common  as  others.  .  .  .  Acute  mania 
may  be  defined  as  intense  mental  exaltation  with  great  excitement, 
complete  loss  of  self-control,  with  sometimes  absolute  incoherence 
of  speech  and  loss  of  consciousness  and  memory.     After  twelve 


MANIA.  255 

months  it  is  arbitrarily  no  longer  reckoned  acute  but  chronic 
mania.  Some  authors  set  up  a  period  of  forty  days  during  which 
alone  the  disease  was  to  be  called  acute  mania.  This  had  no 
foundation  in  any  clinical  fact. 

"  Acute  mania  begins  in  various  ways.  The  most  common  is 
by  its  commencing  as  simple  mania  and  then  passing  into  the 
acute  form.  But  I  have  seen  it  begin  quite  suddenly,  the  patient 
being  one  hour  a  sane,  rational,  responsible  being,  and  the  next 
acutely  maniacal.  It  has  often  a  melancholic  prelude.  It  some- 
times begins  by  the  patient  expressing  a  delusion  out  of  which,  as 
it  were,  the  extravagances  seem  to  arise.  Sometimes  it  begins  by 
emotional,  sometimes  by  intellectual  exaltations  and  perversions, 
sometimes  by  both.  At  other  times  it  begins  by  alterations  of 
habit,  appetite,  and  propensity.  It  commonly  has  premonitory 
symptoms,  bodily  and  mental,  such  as  headaches,  a  confused  feel- 
ing in  the  head,  a  muscular  fidgetiveness,  an  unrest  of  body  and 
mind,  a  feeling  that  something  is  going  wrong  or  something  dread- 
ful is  to  happen,  a  feeling  of  wild  commotion  in  the  head,  as  if  it 
were  about  to  burst,  an  impulsive  desire  to  do  something,  to 
break  glass  or  to  do  violence  to  those  within  reach.  There  are 
usually  disturbed  sleep  and  constant  dreaming,  usually  of  an 
unpleasant  kind.  I  have  known  the  temperature  to  rise  to  over 
one  hundred  before  the  patient  could  be  said  to  be  in  any  way 
maniacal. 

"Krafft-Ebing  has  given  a  series  of  interesting  clinical  lectures 
upon  this  subject.  He  defines  mania  as  a  psycho-neurosis  char- 
acterized by  well-marked  discordance,  exalted  sensation  of  im- 
pressions,— an  abnormal  sequence  of  psychological  phenomena. 
Krafft-Ebing's  theory  of  the  brain-condition  in  mania  is  of  h  vper- 
eemia.  He  says,  '  I  think  there  can  be  little  doubt  that  in  mania 
we  have  a  supernutrition  with  an  overheating  of  the  psychical 
machine.' 

"  He  divides  mania  into  two  sections,  designating  them  mania 
mitis  and  mania  gravis,  suggesting  as  synonymes  maniacal  exal- 
tation and  madness."  * 

What,  now,  are  the  characteristics  of  mania  by  which  we  may 
be  enabled  to  diagnose  it  without  difBculty  ?     All  cases  of  mania 


*  Brush,  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 


256  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

present  more  or  less  excitement, — mental  excitement, — evinced 
by  incoherent  conversation,  showing  an  irrational  state  of  the 
mental  faculties  and  a  morbid  association  of  ideas,  to  which  are 
added  wild  gesticulations  and  almost  constant  motion.  Maniacs 
dance,  sing,  and  jump  without  adequate  cause ;  their  actions  are 
violent  and  excited,  their  fury  quite  beyond  their  own  control. 
These  are  the  usual  symptoms,  the  ideational  insanity  being 
plainly  shown  by  the  conversation  of  such  patients ;  but  there 
is,  nevertheless,  a  perversion  of  the  affective  life  underlying  the 
disease  and  deeply  impressing  all  its  manifestations.  This  neces- 
sarily displays  itself  in  action,  and  the  patients  are  restless  and 
destructive.  They  are  difficult  to  manage,  and  their  volubility  is 
truly  astonishing.  This  fact  caused  the  older  writers  to  contend 
that  in  maniacs  the  memory,  as  well  as  all  the  other  mental  facul- 
ties, became  enhanced  or  brightened.  Although  such  people  show 
remarkable  mental  activity,  "  a  complete  change  of  emotional  state, 
thus  often  becoming  very  joyous ;  a  rapid  and  uncontrolled  passing 
of  the  ideas  through  the  mind ;  vivid  kaleidoscopic  mental  pic- 
tures of  the  past ;  a  tendency  to  constant  talking,  whether  any  one 
is  present  or  not ;  passing  from  one  thing  to  another,  and  soon 
becoming  incoherent  of  speech ;"  speaking  not  infrequently  in 
rhyme  with  astonishing  facility,  still  these  are  no  proofs  of  the 
above  assertion,  but  simply  point  to  abnormal  increase  of  func- 
tional activity,  resulting  from  disease.  The  mental  mechanism  is 
deranged.  There  is  a  defect  in  intellectual  co-ordination,  due  to  the 
absence  of  a  controlling  power.  Not  only  is  co-ordination  neces- 
sary to  the  regularity  and  precision  of  muscular  action,  but  mental 
action  must  also  be  governed  by  the  same  regulating  influence, 
and  in  the  cerebral  hemispheres  such  inhibitory  centres  undoubtedly 
exist.  As  M.  Allen  Starr,  in  his  "  Familiar  Forms  of  Nervous 
Diseases,"  very  aptly  remarks,  "Thought  does  not  lead  imme- 
diately to  expression  in  all  cases.  Expression  may  be  restrained  : 
the  impulse  may  be  arrested.  This  restraint  of  the  flow  of  thought 
outward  in  expression  has  been  termed  inhibition;  and  inhibition, 
or  the  act  of  control,  is  the  highest  of  all  the  cortical  functions." 
When  this  inhibitory  influence  fails  to  act,  or  acts  imperfectly, 
there  is,  figuratively  speaking,  a  loosening  of  some  contact,  in 
electrical  parlance,  or  some  lever  is  out  of  order ;  and,  though 
the  machine  may  be  in  rapid  and  continuous    motion,  with  a 


MANIA.  257 

striking  evolution  of  thought  and  brilliant  scintillations  of  fancy, 
still,  the  ideational  workings  are  abnormally  performed,  and  the 
intellect  is  impaired.  We  have  here  a  condition  of  irritability 
of  the  brain,  the  same  that  exists  in  hyperemia,  or  in  inflam- 
matory conditions  of  the  brain-envelopes.  You  remember  that 
when  speaking  of  meningeal  inflammation  I  told  you  that  the 
symptoms  of  irritation  preceded  those  of  depression.  So  we  have 
in  mania  a  certain  hypersesthetic  state  of  the  nerves  of  special 
sense,  and  of  the  perceptive  and  psychical  powers,  giving  rise  to 
the  symptoms  of  irritation,  whose  pathology  is  very  similar  to  that 
of  congestive  diseases.  There  is,  of  course,  an  increased  flow  of 
ideas,  the  mental  powers  are  acting  abnormally,  and  there  is  a 
greater  scope,  though  less  perfection  of  activity,  which  corresponds 
with  the  concomitant  symptoms  of  irritation.  "  There  may  be 
ceaseless  laughing,  or  scolding,  or  swearing ;  conversations  are 
held  in  loud  tones  with  imaginary  people  whose  voices  are  some- 
times heard  or  their  forms  seen.  Sometimes  there  is  rhythmic 
action  of  mental  and  muscular  centres  seen,  evinced  by  rhyming 
all  the  ordinary  conversation,  or  by  regular  movements  of  the 
limbs  and  body."  But,  as  the  malady  progresses,  the  patient  Ls 
finally  completely  lost  in  the  labyrinth  of  mental  disease,  and 
dementia  appears,  a  state  corresponding  with  the  symptoms  of 
depression  of  meningitis,  and  fatuity  may  be  anticipated.  In 
maniacal  excitement,  and  the  dementia  which  follows,  there  is  at 
first  an  increase  and  then  a  decrease  of  mental  activity,  invariably 
accompanied  by  very  imperfect  performance  of  the  intellectual  and 
moral  functions.  "  Conversations  with  old  friends  now  dead  will 
be  carried  on.  Scenes  of  childhood  and  years  gone  by  will  be 
vividly  realized.  Self-control  may  be  utterly  lost ;  the  tempera- 
ture over  99°;  the  pulse  quick  and  sometimes  fiill  ;  the  skin 
moist ;  the  tongue  furred ;  the  appetite  gone ;  the  tastes  and  sense 
of  decorum  and  decency  perverted."     (Clouston.) 

To  illustrate  this,  suppose  the  case  of  a  man  who  in  rowing  a 
boat,  instead  of  making  slow  and  regular  strokes,  lacks  the  neces- 
sary co-ordinating  power  of  muscular  action,  and  makes  violent 
and  spasmodic  efforts,  which  necessitate  a  considerable  though 
inadequate  and  improperly  regulated  expenditure  of  strength  ;  his 
exertions  effect  but  little  ;  many  of  his  strokes  would  hardly  equal 
one  regular  and  natural  sweep  of  the  oars.     In  mania  there  may 

17 


258  DISEASES   OF   THE   NERVOUS   SYSTEM. 

be  more  mental  activity,  but  its  vigor,  far  from  being  increased,  is 
diminished. 

The  most  prominent  symptom  of  mania  is  the  mental  excite- 
ment, and,  correspondingly,  we  always  find  an  exaggerated  feeling 
of  self-esteem  and  self-exaltation.  The  patient,  in  his  own  esti- 
mation, is  better  than  anybody  else ;  and  there  always  exists  a 
presumptive  superiority  of  some  kind.  Schroeder  van  der  Kolk 
holds  this  to  be  an  indispensable  symptom.  Obstinate  insomnia, 
especially  in  the  earlier  stages,  is  rarely  absent.  With  this  fact 
all  physicians  treating  insanity  are  familiar.  Troublesome  con- 
stipation is  usual.  A  remarkable  tendency  to  the  manifestation 
of  thought  by  action  is  characteristic  of  mania.  Certain  actions, 
representing  thoughts,  almost  simultaneously  accompany  their 
utterance  in  words.  Such  patients  therefore  gesticulate  violently, 
and  act  while  speaking.  The  impulse  to  incessant  motion  is  truly 
remarkable,  and  sometimes  quite  dangerous,  a  fact  which  is  inter- 
esting in  a  medico-legal  point  of  view.  "  Thought  is  father  to 
the  impulse  ;"  but  here  the  thought  is  hardly  recognized  before  the 
muscular  action  gives  it  expression.  It  is  in  consequence  of  this 
that  such  patients  run,  dance,  sing,  kill,  and  destroy.  Because  of 
this  tendency  to  the  exhibition  of  thought  in  external  action  they 
are  in  constant  mischief  and  trouble.  I  hope  you  will  all  seize 
the  important  distinction,  that  when  the  violence  of  action  mani- 
fests itself  by  suicide,  homicide,  etc.,  such  is  not  the  only  expres- 
sion of  the  insanity ;  other  well-marked  symptoms  will  be  found 
to  coexist.  Dangerous  propensities  alone  cannot  correctly  define 
distinct  forms  of  insanity.  On  these  grounds  I  exclude  pyromania, 
erotomania,  dipsomania,  homicidal  and  suicidal  mania,  as  types  of 
insanity,  simply  because  they  embrace  only  a  single  sign  or  symp- 
tomatic indication  of  the  existence  of  unmistakable  insanity ;  just 
as  cough  does  not  constitute  pneumonia  or  bronchitis,  but  is  only 
one  of  its  accompaniments. 

The  course  of  mania  is  very  uncertain  ;  it  may  last  a  week,  a 
month,  or  a  lifetime.  The  tendency  of  the  disease  is  either  towards 
a  favorable  termination  or  to  chronicity ;  or  it  may  result  in  de- 
mentia,— the  "  tomb  of  reason :"  once  herein  engulfed,  man  is  no 
longer  a  rational  creature,  and  that  divine  attribute  which  dis- 
tinguishes him  from  the  animal  is  lost  forever. 

It  is  of  course  advisable  to  treat  the  disease  in  the  early  or 


MANIA.  259 

inceptive  stage  wlien  possible.  The  moral  treatment  is  as  indis- 
pensable in  mania  as  it  is  in  melancholia,  and  hence  asylum  dis- 
cipline should  be  resorted  to  early.  Mania,  to  some  extent  at  least, 
seems  to  yield  to  therapeutic  measures,  and  the  bromides  of  potas- 
sium, calcium,  sodium,  and  lithium  have  been  employed  with  ad- 
vantage, on  account  of  their  sedative  powers,  and  their  controlling 
influence  over  the  circulation  of  the  brain.  When  we  come  to 
study  the  pathology  of  insanity,  we  shall  see  that  there  may  be 
not  only  too  much  blood  in  the  brain,  but  also  too  little,  and  that 
the  blood  may  be  abnormal  in  quality  as  well  as  in  quantity,  re- 
sulting in  "  irritable  weakness.^'  It  follows  that  while  bromide  of 
potassium  may  be  serviceable  in  some  cases  of  mania,  in  others 
it  will  be  productive  of  harm  ;  as,  for  instance,  when  an  ansemic 
condition  of  the  brain  exists. 

The  insomnia  must  be  combated.  I  have  already  recom- 
mended hydrate  of  chloral ;  .  but  I  consider  sulfonal  to  be  the 
hypnotic  par  excellence.  Free  pustulation  of  the  head,  by  the 
application  of  croton  oil  to  the  scalp,  often  acts  marvellously  in 
relieving  the  patient,  especially  when  the  disease  is  becoming  sub- 
acute in  character.  Sulphate  of  copper,  ergot,  and  Indian  hemp, 
combined  with  the  bromides,  as  recommended  by  a  distinguished 
foreign  authority,  cold  aiFusion  and  tepid  baths,  cautiously  ad- 
ministered, the  hypodermic  injection  of  morphine  and  hyoseyamus 
(often  exceedingly  efficient),  are  remedies  which  have  all  proved 
useful  in  my  hands  for  the  treatment  of  intense  maniacal  excite- 
ment. When  the  motor  centres  are  seriously  implicated,  I  believe 
that  conium  is  a  most  useful  remedy,  and  will  produce  striking 
results  in  quieting  the  restlessness,  jactitation,  and  general  excite- 
ment. As  tonics  in  subsequent,  stages,  I  have  found  none  equal 
to  cod-liver  oil,  dilute  phosphoric  acid,  quinine,  and  the  prepa- 
rations of  iron.  In  mania,  a  cautious  hypodermic  injection  of 
sulphate  of  hyoscyamine  (hydrobromate  of  hyoscine  I  do  not 
consider  safe)  is  one  of  the  best  hypnotics,  and  hydrobromate  of 
Conine  one  of  the  best  agents  to  quiet  motor  excitement  that  I 
have  ever  used. 

The  hygienic  conditions  should  not  be  neglected.  Let  us  never 
forget  that  the  excitement  is  accompanied  by  excessive  retrograde 
metamorphosis  of  tissue,  and  keeps  pace  with  these  destructive 
changes.     In  acute  mania,  therefore,  you  should  always  admin- 


260  DISEASES   OF   THE   XERVOUS   SYSTEM. 

ister  large  quantities  of  nutriment ;  and,  where  the  patient  resists, 
it  is  your  duty  to  compel  him  to  take  it,  even,  if  you  must,  by 
the  stomach-pump.  Sudden  death  often  occurs  from  intense  ex- 
citement, when  followed  by  corresponding  depression  and  exhaus- 
tion. Whenever  very  intense  activity  exists,  whether  functional 
or  organic,  you  have  reason  to  dread  the  consequent  reaction. 

The  prognosis  depends  greatly  upon  the  duration  of  the  disease, 
the  age  of  the  patient,  and  the  number  of  previous  attacks.  If 
the  family  history  point  to  insanity,  you  may  reasonably  fear  a 
relapse,  and  hence  will  give  a  guarded  opinion ;  one  attack  of 
insanity  always  predisposes  to  another,  and  this  more  particularly 
when  the  patient  is  of  an  insane  temperament. 

MONOMANIA    (pARANOIA). 

"What  is  monomania?  It  is  a  partial,  a  delusional  form  of 
insanity ;  and  the  name  is  derived  from  the  Greek  words  p-6'^oq 
(single),  and  /Jta^ia  (mania),  as  it  was  supposed  to  be  an  insanity 
upon  one  particular  point,  or  a  disease  of  only  one  portion  of  the 
brain.  In  monomania  the  intellect  is  apparently  clear,  or  even 
unusual  mental  activity  is  at  times  exhibited,  except  upon  a  single 
point,  or  perhaps  a  few  points,  indicative  of  the  patient's  insanit}\ 
This  form  has  also  been  called  delusional  insanity,  because  the 
disease  is  always  expressed  by  one  or  more  delusions.  Overween- 
ing self-esteem  exists  in  monomania  even  to  a  greater  degree  than 
in  mania.  It  is  an  almost  invariable  concomitant  of  the  disease, 
and  I  have  never  seen  a  case  in  which  it  did  not  constitute  a  well- 
marked  feature.  Such  persons  grow  exceedingly  angry  if  you 
diifer  with  them  in  opinion.  They  are  often  very  intelligent,  and 
may  astound  you  by  the  acuteness  of  their  reasoning  powers,  their 
general  information,  and  their  brilliancy  of  thought. 

Are  we  to  understand  that  such  a  thing  can  really  exist  as 
a  partial  insanity?  Can  an  individual  be  non  compos  mentis 
to  a  limited  degree  and  mentally  sound  otherwise  ?  Can  a  truly 
definite  pathological  condition  of  the  mind  ever  be  truly  partial  ? 
Can  a  man  be  insane  in  one  or  two  ideas  and  mentally  sound  in 
all  others  ?  I  am  not  inclined  to  believe  such  a  doctrine,  but 
prefer  to  think  that  in  this  aifection  the  mind  is  more  or  less  com- 
pletely impressed  or  biassed  by  the  delusion  or  group  of  delusions. 
It  does  not  follow  that  because  a  man  is  seemingly  insane  upon 


MONOMANIA.  261 

but  one  subject  he  is  sane  in  all  other  respects,  since  we  cannot 
measure  the  extent  of  his  irrationality,  or  positively  ascertain  the 
exact  limits  of  his  unsoundness.  We  cannot  restrict  disease  of 
the  mind  by  any  arbitrary  barrier.  I  cannot  conceive  of  the 
existence  of  a  delusion  unless  a  greater  or  less  implication  of  some, 
if  not  of  all,  of  the  mental  faculties  coexists  as  a  result  thereof. 
This  may  not  l>e  apparent  on  examination,  but  for  all  practical 
purposes  we  can  accept  it  without  hesitation. 

By  way  of  illustration,  I  may  remark  that  I  once  knew  a  man 
who  was  on  trial  for  some  crime  :  he  was  examined  by  a  com- 
mittee of  experts,  who,  after  a  careful  investigation,  could  find 
no  evidence  of  insanity.  A  relation  of  the  accused,  however, 
requested  his  attorney  to  ask  him  "  why  he  was  more  powerful 
than  other  men."  His  manner  immediately  changed;  and  he 
replied,  with  great  vehemence,  that  he  "  held  his  power  from  the 
source  of  all  glory,  and  was  on  terms  of  social  equality  w^ith  the 
Holy  Ghost,  and  with  other  members  of  the  Trinity,  being  in 
the  habit  of  treating  them  to  the  best  of  liquors."  Men  vnll  labor 
under  such  delusions,  believing  them  as  firmly  as  you  would 
believe  a  mathematical  fact.  All  the  regions  of  the  mind  are,  to 
some  extent,  pervaded  by  such  delusions,  when  they  exist ;  and  a 
man  in  such  a  condition  must,  to  some  extent,  be  mentally  unsound 
in  every  other  respect.  A  person  laboring  under  monomania, 
though  apparently  sane  in  many  particulars,  is,  nevertheless,  en- 
tirely non  compos  mentis,  and  ought,  in  most  instances,  to  be 
secluded  in  a  lunatic  asylum ;  for  when  subjected  to  the  soothing 
influences  of  such  a  retreat  he  may  cause  little  or  no  trouble,  but 
if  brought  in  contact  with  the  world,  where  he  would  be  liable  to 
be  crossed,  he  might  become  dangerous,  or  even  perpetrate  some 
fearful  deed. 

It  is  a  fact  of  special  pathological  significance  that  this  disorder 
is  rarely  primary.  The  anamnesis  generally  shows  a  previous 
attack  of  mania,  possibly  of  melancholia.  The  patient  has  been 
apparently  cured,  having  become  comparatively  rational,  with  the 
exception  perhaps  of  some  one  lingering  delusion,  from  which  he 
never  recovers.  I  have  had  more  than  twenty-five  years'  experi- 
ence in  the  treatment  of  insanity,  and  do  not  know  of  a  single  case 
of  cure  of  monomania.  In  cases  of  apparent  cure  there  has  been  a 
cessation  of  the  previous  primary  pathological  processes,  consisting 


262  DISEASES   OF   THE   NERVOUS   SYSTEM. 

simply  in  a  diminution  of  their  intensity  and  perhaps  of  their 
extent.  Monomania  does  not  commence  as  such  by  any  primary 
pathological  change.  We  know  that  insanity  is  always  a  disease 
of  the  brain,  but  monomania  is  generally  the  result  of  some  other 
form  of  insanity,  in  the  convalescence  from  which  there  has  been 
a  clearing  up  of  the  morbid  condition  to  a  certain  point,  at  which 
it  is  arrested,  and  thus  monomania  remains  for  life. 

PAEANOIA. 

This  term,  which  so  frequently  occurs  (Spitzka  classifies  para- 
noia with  monomania)  in  the  psychopathic  literature  of  the  day, 
is  defined  by  Billings,  in  his  "  National  Medical  Dictionary,"  as 
"  unsoundness  of  mind,  crankiness,  insane  diathesis,  hereditary  or 
acquired  chronic  mental  instability ;  the  '  protopathic  insanity'  of 
Bucknill  and  Tuke.  Sometimes  used  to  signify  monomania  with 
delusions." 
/  M.  Allen  Starr,  in  his  recent  work  on  "Familiar  Forms  of 

K>,      Nervous  Disease,"  states  that  "  in  most  of  the  cases  of  paranoia 
y       a  hereditary  history  was  readily  elicited.    All  had  either  fixed  sys- 
d  tematized  persecutory  delusions  alone,  or  these  in  combination  with 

delusions  of  a  grandiose  character."  "  A  typical  case  of  paranoia 
exhibits  certain  positive  features  which  make  this  form  of  insanity 
a  clinical  syndrome.  There  are  hereditary  taints ;  some  eccen- 
tricities in  childhood  ;  more  marked  peculiarities  during  youth, 
often  associated  with  a  degree  of  hypochondriasis ;  and  at  about 
the  age  of  thirty,  sometimes  earlier,  sometimes  later,  the  growth 
and  systematization  of  delusions  of  perseeution,  which  may  in  turn 
be  combined  with  or  give  place  to  systematized  delusions  of  an 
exalted  character  (either  religious,  philosophic,  patriotic,  or  erotic). 
Such  delusions  completely  dominate  their  entire  mental  action 
without  impairing  every  faculty." 

These  cases  were  formerly  called  "  monomania"  by  American 
authorities,  and  are  classified  as  "monomania"  or  "delusional 
insanity"  by  nearly  all  tlie  English  writers. 

As  M.  Allen  Starr  further  observes,  "  The  eccentric  individuals 
known  as  '  cranks'  are  without  doubt  imperfectly  developed  cases 
of  paranoia." 

In  conclusion,  Starr  continues,  "  As  regards  the  treatment  of 
these  patients,  little  can  be  done  except  perhaps  in  the  way  of 


DEMENTIA.  263 

moral  methods,  and  these  are  of  most  value  in  the  earliest  stages. 
They  may  abort  the  psychosis.  The  asylums  are  the  destination 
of  most  paranoiacs,  and  in  the  best  of  these  institutions  the  disci- 
pline, employment,  recreations,  and  regularity  of  eating  and  sleep- 
ing- exercise  a  beneficial  influence  upon  the  course  of  the  disease. 

"  Paranoiacs  should  be  very  carefully  examined,  especially  those 
with  persecutory  delusions,  as  to  the  presence  of  ideas  of  retaliation 
and  vengeance  upon  their  persecutors.  If  there  is  any  suspicion 
of  their  possessing  dangerous  tendencies,  they  should,  of  course, 
be  deprived  of  their  liberty  as  soon  as  possible." 

The  next  form  of  insanity  to  which  I  desire  to  call  your  atten- 
tion is 

DEMENTIA. 

I  have  very  little  to  say  concerning  this  affection,  having 
already  spoken  of  it  as  "  the  tomb  of  reason."  Some  speak  of 
acute  dementia,  as  distinguished  from  secondary  dementia.  By 
acute  dementia  is  meant  that  condition  which  sometimes  follows 
severe  fevers,  moral  shocks,  or  physical  injuries.  In  these  in- 
stances the  mind,  for  a  time,  becomes  a  perfect  blank.  I  will 
illustrate  this  by  a  case  which  Professor  Dickson,  of  Philadel- 
phia, was  accustomed  to  relate  to  his  class.  A  very  eminent  and 
erudite  divine,  of  New  Jersey,  suffered  from  a  severe  attack  of 
typhoid  fever,  from  the  immediate  effects  of  which  he  recovered, 
but  his  mind  was  completely  wrecked.  He  had  forgotten  every- 
thing,— could  write  or  speak  upon  no  subject,  having  ceased  to 
remember  not  only  the  elements  of  arithmetic,  but  even  the  al- 
phabet. Being  an  industrious  man,  and  possessing  great  tenacity 
of  purpose,  he  was  not  overcome  by  his  calamity,  but  imme- 
diately commenced  to  study  energetically,  in  order  to  acquire  the 
rudiments  of  an  ordinary  education,  and  thus  regain,  if  possible, 
all  he  had  lost.  One  morning,  after  months  had  elapsed,  the 
darkness  and  obscuring  clouds  with  which  his  mind  had  been  sur- 
rounded were  suddenly  dispersed,  the  light  dawned  upon  him,  and 
he  found  himself  possessed  of  his  memory  once  more.  It  was 
like  the  reappearance  of  the  sun  after  temporary  obscuration  by 
a  passing  cloud. 

Asphyxia  may  have  the  same  result.  I  remember  being  once 
asked  by  a  lawyer,  during  a  cross-examination,  a  question  very 
pertinent  to  the  subject  we   are   now  studying.      A  gas   com- 


264  DISEASES    OF    THE    NERVOUS   SYSTEM. 

pany  had  been  sued  for  damages  on  account  of  negligently 
allowing  the  escape  of  gas,  which  was  alleged  to  have  produced 
acute  dementia  in  an  employee,  who  had  been  resuscitated  from  a 
dangerous  state  of  asphyxia.  It  Avas  contended  by  the  defence 
that  gas  could  not  have  had  such  an  effect,  and  that  the  insanity 
must  have  pre-existed.  The  attorney  for  the  company,  desirous 
of  showing  the  similarity  of  effects  between  the  different  forms 
of  asphyxia,  many  of  which  he  contended  were  very  commonly 
known  and  had  never  been  supposed  to  result  in  insanity,  asked 
whether  I  had  ever  heard  of  strangulation  resulting;  in  mental 
impairment.  I  replied  in  the  affirmative.  In  any  variety  of 
strangulation  the  blood  becomes  super-carbonized,  and  necessarily 
produces  deleterious  changes  in  the  brain,  which  may  result  in 
some  form  or  other  of  insanity,  perhaps  more  frequently  in  acute 
dementia,  damaging  the  individual  very  seriously.  The  lawyer, 
desiring  to  propound  a  perplexing  and,  as  he  suj)posed,  absurd 
question,  inquired,  "  Suppose,  doctor,  that  a  man  bo  almost 
drowned,  just  saved  in  time  to  be  revived :  do  you  mean  to  say 
that  this  might  result  in  grave  mental  impairment?"  "Why,  of 
course,"  I  replied :  "  you  have  furnished  me  with  an  excellent 
illustration,  demonstrating  how  asphyxia  may  result  in  acute  de- 
mentia independently  of  what  has  caused  the  asphyxia."  This 
shows  the  importance  of  being  able  to  turn  their  own  weapons 
against  those  who  point  them ;  for  many  lawyers  find  no  little 
satisfaction  in  making  medical  men  aj)pear  ridiculous  when  called 
upon  the  witness-stand. 

By  chronic  or  secondary  or  terminal  dementia  is  meant  that 
form  which  follows  the  acute  varieties  of  insanity,  either  mania 
or  melancholia,  etc.  When  you  pass  through  the  wards  of  an 
insane  asylum,  you  will  recognize  such  patients  by  their  blank 
countenances.  There  is  an  entire  absence  of  intellect,  and  an 
incapacity,  more  or  less  developed,  for  performing  any  rational 
action.  You  will,  perhaps,  see  them  fondly  nursing  a  stick  of 
wood,  believing  it  to  be  a  favorite  child,  or  in  the  active  pursuit 
of  some  delusion ;  in  fact,  they  are  reduced  to  perfect  imbe- 
cility, and  this  disease  is  the  gulf  into  Avhich  the  various  forms 
of  insanity  may  drift.  Dementia  presents  the  traces  of  violent 
precursory  storms,  which  have  stranded  the  nobler  faculties  of 
man,  thus  animalizing  him.     Many  have  not  the  instincts  of 


DEMENTIA.  265 

beasts,  their  lives  being  purely  vegetative.  Here  again  we  see  the 
necessity  for  a  proper  treatment  of  acute  insanity  ;  for  -what  can 
be  more  terrible  than  this  condition  of  abject  mental  degradation  ? 
The  culpable  neglect  of  the  physician  in  not  sending  such  un- 
fortunate beings,  while  yet  in  a  curable  condition,  to  an  asylum, 
entails  upon  them  a  life  of  misery.  When  sent  to  an  asylum  they 
are  but  too  often  already  hopelessly  demented,  and  reduced  to  a 
condition  which  is  horrible  to  witness.  They  are  so  filthy  as  often 
to  eat  their  own  excrements  ;  and  it  will  excite  your  sympathy  to 
remember  that  these  people  were  once  rational  beings  like  your- 
selves, and  that  their  fate  might  have  been,  at  least,  partly  averted 
by  timely  assistance. 

The  following  quotations  concerning  dementia  are  made  from 
Savage's  recent  work  on  "  Insanity  and  Allied  Neuroses  :" 

"In  considerino;  dementia  I  shall  make  two  clear  divisions. 
In  one  there  is  destruction,  more  or  less  complete,  of  the  mind, 
which  can  never  be  recovered  from,  and  in  the  other  there  is 
functional  arrest,  which  may  pass  off.  .  .  . 

"  As  mental  life  begins  with  but  little  evidence  of  intellect,  and 
with  imperfectly  organized  sense-impressions  and  motor  impulses, 
so  it  may  end  with  a  return  to  its  simplicity  in  age.  At  the 
one  end  of  life  there  may  be  inability  to  develop  intellectually ; 
this  is  called  amentia;  and  at  the  other  end  destruction  of  mind 
may  leave  the  whole  intellectual  fabric  a  ruin ;  this  is  called 
dementia.  .  .  . 

"  No  two  houses  fall  into  ruins  in  exactly  the  same  way,  though 
in  the  end  the  four  walls  alone  may  remain  as  evidence  of  the  once- 
inhabited  dwelling ;  and  so  with  mental  destruction,  it  will  be 
found  that,  though  in  the  end  similar  foundations  and  simple 
boundaries  of  mind  may  remain,  all  the  finer  parts  are  removed  : 
whether  age,  war,  or  fire  has  destroyed  the  houses,  the  results  are 
alike ;  similarly,  either  age,  disease,  or  injury  may  wreck  the  mind. 
It  will  be  seen  that  the  mind  may  show  the  effects  of  destruction 
in  various  ways,  and  the  destruction  may  progress  at  very  different 
rates.  There  is  no  such  thing  as  complete  dementia,  for  life  could 
not  exist  with  total  suppression  of  mind  and  sense-reaction.  .  .  . 

"  Dementia  is  divided  into  primary  and  secondary. 

"  In  complete  general  dementia  there  exists  a  general  weakness 
of  the  senses,  the  memory,  and  the  higher  organizing  and  con- 


266  DISEASES   OF   THE   NERVOUS   SYSTEM. 

trolling  power.  The  senses  react  slowly  to  their  respective  stimuli, 
reflex  actions  are  performed,  and  in  some  cases  the  loss  of  the 
higher  control  causes  reflex  action  to  be  rendered  more  rapid  and 
more  active  than  in  health. 

"  Many  acts  are  done  automatically.  The  power  of  storing 
impressions  is  greatly  impaired,  or  even  annihilated,  so  that  the 
memory  for  recent  impressions  is  wantmg,  and  memory  of  the 
past  is  somewhat  affected.  There  is  no  evidence  of  volition,  and 
emotional  display  is  rare.  The  loss  of  self-  and  general  control  is 
marked.  .  .  . 
,    "  Of  course  the  mental  faculties  are  nearly  abolished. 

"  Appetite  and  digestion  may  be  good,  but  the  patients  are 
usually  dirty  and  neglectful  in  their  habits.  They  usually  sleep 
well.  Persons  thus  afflicted  generally  have  to  be  fed,  washed,  and 
cared  for  like  children. 

"Dementia  may  be  due  to  either  physical  or  mental  disease. 
Among  the  purely  physical  causes,  fevers  very  frequently  produce 
it,  especially  typhoid  fever,  which  is  known  not  infrequently  to 
seriously  impair  the  memory  for  a  longer  or  shorter  period.  Alco- 
holic and  other  excesses,  rheumatism,  sypliilis,  epile]3sy,  child- 
bearing,  blows  on  the  head,  pneumonia,  previous  attacks  of 
mental  disorders,  are  all  well-kno^vn  factors  in  the  production  of 
dementia." 

MORAL   INSANITY. 

What  is  moral  insanity  ?  Is  it  an  insanity  of  a  man's  morals  ? 
Is  it  that  condition  in  which  an  individual  has  impairment  of 
mind,  destroying  his  knowledge  of  right  and  wrong,  and  by  which 
he  is  led  to  commit  nefarious  deeds  ?  Is  such  moral  insanity  ?  It 
is  very  important  to  understand  this  subject,  as  it  is  often  consti- 
tuted a  plea  in  legal  cases.  It  is  never  moral  depravity,  and  moral 
depravity  is  not  always  moral  insanity.  If  you  realize  this,  you 
have  made  an  important  step  in  advance.  In  a  previous  lecture, 
when  I  cited  Blandford's  illustration  of  an  Italian  brigand,  accus- 
tomed to  kill  and  plunder,  I  showed  you  distinctly  that  this  was 
not  moral  insanity,  but  only  a  blunting  of  the  conscience  by  the 
habitual  commission  of  crime.  I  maintain  that  moral  insanity  is 
but  a  variety,  perhaps  a  peculiar  form  of  the  affective  type  of 
insanity,  of  which  you  have  lately  heard  so  much.  Affective, 
impulsive,  pathetic,  emotional,  and  moral  insanity  are  virtually 


MORAL   INSANITY.  267 

the  same,  each  and  all  of  them  belonging  to  the  same  type,  as  they 
all  relate  to  action.  Pritchard,  who  first  described  moral  insanity, 
attached  great  importance  to  it,  especially  in  a  medico-legal  point 
of  view.  He  maintained  that  in  moral  insanity  there  was  no  evi- 
dence, to  any  degree,  of  intellectual  impairment  or  implication, 
and  that  the  judgment,  memory,  cognition,  and  perceptive  powers 
were  normal,  but  that  there  was  a  perversion  of  the  moral  faculties, 
resulting  in  a  change  of  the  habits,  feelings,  affections,  propensities, 
and  sentiments  of  an  individual,  sometimes,  though  most  rarely, 
accompanied  by  delusions,  whereby  he  was  rendered  insane  and 
irresponsible.  He  defines  it,  to  use  his  own  words,  as  "  a  morbid 
perversion  of  the  natural  feelings,  aifections,  inclinations,  habits, 
moral  dispositions,  and  natural  impulses,  without  any  remarkable 
disorder  or  defect  of  the  intellect  or  knowing  or  reasoning  facul- 
ties, and  particularly  without  any  insane  illusion  or  hallucination." 
I  formerly  believed  this  to  be  true,  but  am  now  satisfied  that  in 
every  case  related  by  Pritchard  more  or  less  mental  weakness  or 
impairment  existed,  discoverable  had  it  been  carefully  sought  for  ; 
and  while  I  consider  moral  insanity  to  be  a  morbid  perversion  of 
the  moral  faculties,  T  am  satisfied  that  every  case  is  accompanied 
by  more  or  less  mental  defect ;  in  other  words,  in  moral  insanity 
more  or  less  ideational  insanity  always  exists,  though  it  is  not 
always  apparent  nor  always  readily  discoverable. 

Pinel,  referring  to  this  class  of  cases,  states  that  moral  insanity 
is  largely  a  matter  of  bad  education.  Folsom  observes  that  in- 
sanity of  a  purely  moral  character  is  "  an  uncontrollable  violence 
of  the  emotions  and  instincts,  and  is  probably  as  rare  as  purely 
intellectual  insanity." 

In  another  place  the  latter  remarks  that  moral  insanity  "is 
recognized  by  all  the  authorities  on  mental  disease,  whatever  may 
be  their  opinions  as  to  the  limitations  of  responsibility  in  it.  It 
is  esiDccially  to  it  that  we  can  apply  the  words  of  the  Autocrat  of 
the  Breakfast -Table,  that  the  worst  forms  of  insanity  are  those  to 
which  the  asylum  shuts  its  doors.  It  is  marked  by  moral  per- 
version, change  of  character  and  action,  and  so  little  intellectual 
impairment  as  to  be  easily  overlooked  by  one  not  familiar  with 
morbid  mental  phenomena." 

We  particularly  agree  with  Folsom  when  he  asserts  that, 
"  Although  moral  insanity  is  probably  a  common  cause  of  young 


268  DISEASES   OF   THE   NERVOUS   SYSTEM. 

persons  of  both  sexes  being  led  into  lives  of  licentiousness,  wicked- 
ness, and  crime,  it  is  to  be  carefully  differentiated  from  deliberate 
yielding  to  temptation  and  following  lives  of  vice  until  a  strong 
enough  motive  is  offered  for  doing  better  or  a  punishment  is  made 
sufficient  to  be  deterrent.  .  .  .  Moral  insanity  is 'a  defect  in  the 
affective  sphere,  but  also  an  intellectual  defect  of  a  peculiar  kind, 
which  is  often  concealed  under  the  mask  of  a  perverted  moral 
sense,  and  which  requires  time  and  practice  on  the  part  of  the 
physician  for  its  detection."     (Westphal.) 

As  to  diagnosis,  I  must  say  that  I  never  accept  the  theory  of 
moral  insanity  without  certain  corroborative  antecedents  of  some 
other  form  of  insanity, — some  evidence  of  the  insane  temperament, 
or  at  least  of  a  strong  taint  of  insanity  in  the  ancestry,  while  I 
also  seek  other  important  links  in  the  history  when  obtainable  ; 
especially  as  the  'present  weight  of  authority  is  negative  as  regards 
its  existence,  and  since,  moreover,  it  is  not  generally  recognized 
by  the  courts.  A  change  in  the  individual's  self  is  a  most  im- 
portant symptomatic  manifestation  :  without  this  as  a  basis  we 
cannot  possibly  affirm  its  existence.  There  must  be  a  change  of 
character,  "without  external  adequate  cause,"  not  explicable  by 
the  ordinary  motives  of  human  actions.  Suppose  a  man  is  way- 
laid and  killed  by  some  miscreant,  the  money  upon  his  person 
stolen,  and  that  the  thief  when  prosecuted  should  enter  a  plea  of 
moral  insanity  with  design  to  defeat  the  law  :  would  not  the  cir- 
cumstances and  the  motive  be  sufficient  to  warrant  an  expert  in 
insanity  in  unhesitatingly  giving  his  testimony  against  such  an 
assumption  ?  But,  on  the  other  hand,  suppose  an  upright,  honest, 
moral  man,  known  for  a  lifetime  to  be  conscientious  and  above 
reproach  in  all  his  relations,  suddenly,  without  motive,  become 
obscene  and  lascivious  in  his  conduct,  evincing  murderous  and 
thieving  propensities  :  if  there  be  superadded  an  insane  ancestry, 
temperament,  or  predisposition,  we  have  certainly  good  evidence 
of  moral  insanity.  If,  however,  moral  insanity  exist,  and  such  a 
case  be  investigated,  a  certain  amount  of  mental  weakness  will  be 
usually  found,  pointing  to  more  or  less  ideational  insanity  as  a 
complication.  Under  such  a  limitation  only  can  I  admit  the 
existence  of  moral  insanity,  but  never  per  se,  or  w^ithout  some 
degree  of  actual  mental  impairment. 

"  But  Dr.   Tuke  has  now  furnished  the  advocates  of  moral 


IDIOCY   AND   IMBECILITY.  269 

insanity  with  an  argument  which  legal  scepticism  will  find  some 
difficulty  in  answering.  Skilfully  abandoning  the  old  definition 
as  untenable,  this  eminent  alienist  contends  that  the  existence  of 
moral  insanity  is  proved  by  the  production  of  cases  in  which  (a) 
disorder  of  the  moral  faculties  is  the  prominent  characteristic,  or 
(6)  there  is  at  least  no  such  intellectual  unsoundness  as  the  law 
would  admit  to  be  an  exculpatory  plea. 

"  But  Dr.  Tukehas  not  contented  himself  with  maintaining  that 
an  entire  absence  of  mental  disorder  is  not  a  necessary /ac^itm^ro- 
bandum  in  the  case  for  moral  insanity.  He  has  placed  on  record, 
temperately,  clearly,  and  with  ample  detail,  at  least  one  case  of 
congenital  moral  defect  in  which  no  lesion  of  the  intellectual 
faculties  appears  to  have  existed.  To  transcribe  the  history  of 
this  case  would  be  unfair  to  the  author,  and  no  precis  of  the  facts 
would  bring  home  to  your  minds  their  full  significance.  I  shall 
conclude  this  brief  communication  by  expressing  my  firm  belief 
that  Dr.  Tuke's  observation  will  be  the  '  locus  classicus'  of  moral 
insanity ;  that  it  justifies  the  cautious  acceptance  of  that  doctrine 
by  which  American  judges  have  honorably  distinguished  them- 
selves ;  that  it  is  worthy  of  consideration  both  by  medical  experts 
and  by  those  whose  duty  it  is  to  cross-examine  them,  and  that  the 
possibility  of  ' primdre  Verruchtheit'  has  been  established  at  last."* 

We  have  now  to  consider  two  other  forms  of  insanity : 

IDIOCY    AND    IMBECILITY. 

By  the  former  is  meant  that  form  of  insanity  which  is  the  result 
of  an  arrest  of  development  or  growth  of  the  brain  either  during 
foetal  life  or  immediately  after  birth.  Imbecility  differs  from  this 
only  in  degree.  In  it  the  arrest  of  mental  development  occurs  at 
a  period  subsequent  to  birth,  often  following  some  pathological 
process.  In  fact,  idiocy  is  an  original  defect  in  the  organization 
of  the  brain,  while  in  imbecility  the  defect  is  adventitious,  for  the 
physical  condition  of  the  brain  may  have  been  perfectly  normal  at 
birth,  or  even  at  a  subsequent  period.  Still,  it  is  as  difficult  to 
draw  a  line  of  distinction  between  idiocy  and  imbecility  as  between 
insanity  and  reason. 

*  A.  "Wood  Eenton,  of  the  London  Bar,  Medico-Legal  Journal,  New  York, 
September,  189L 


270  DISEASES   OF   THE   NERVOUS   SYSTEM. 

(Packard.) 

"  This  is  perhaps  the  most  appropriate  place  in  which  to  men- 
tion a  striking  instance  of  the  extension  of  the  province  of  surgery 
in  a  new  operation,  to  which  has  been  affixed  the  name  of  craniee- 
tomy.  (This  term,  according  to  analogy,  should  signify  removal 
of  the  skull  by  a  cutting  operation ;  linear  craniotomy  would  be 
more  accurately  descriptive  of  the  procedure.)  The  condition 
which  it  is  proposed  to  relieve,  and  which  has  been  thus  treated 
in  several  cases,  is  that  known  as  microcephalus,  or,  more  properly, 
microcephalia. 

"  The  idea  is  that  the  resistance  of  the  imperfectly  developed  or 
prematurely  solidified  skull  checks  and  stimts  the  natural  growth 
of  the  brain,  and  children  so  affected  are  apt  to  be  idiotic  in  a 
greater  or  less  degree.  Hitherto  such  cases  have  been  regarded  as 
beyond  the  reach  of  medical  or  surgical  treatment,  and  as  suscep- 
tible only  of  such  slight  improvement  as  might  be  brought  about 
by  patient  efforts  and  training.  It  is  now  proposed  to  remove  one 
of  the  factors  in  the  arrest  of  development  by  relieving  the  brain  of 
mechanical  compression,  thus  affording  it  opportunity  to  expand. 

"  Gu^niot  claims  to  have  made  the  original  suggestion  of  sur- 
gically relieving  the  brain  of  the  pressure  of  a  too  small  cranium, 
in  a  communication  made  to  the  Academic  de  Medecine  in  No- 
vember, 1889 ;  but  Lannelongue  reported  two  cases  in  which  he 
had  carried  out  the  idea  with  encouraging  success,  and  Keen  has 
operated  in  nearly  a  similar  manner,  the  result  of  the  cases,  how- 
ever, being  not  yet  placed  upon  record.  All  of  these  cases  were 
in  children,  and  the  condition  was  congenital.  But  it  should  be 
noted  that  Bauer  (of  St.  Louis)  mentions  a  case  in  which  he 
trephined  a  man,  aged  twenty-seven  years,  for  acquired  microce- 
phalia from  an  injury  of  the  skull  sustained  sixteen  years  pre- 
viously ;  very  great  improvement  followed,  the  patient  becoming 
able  to  go  into  business,  and  when  seen  six  years  later  being  in  full 
health  and  mentally  sound.  Bauer  reports  that  another  case,  that 
of  '  a  young  woman'  (age  not  stated),  in  whom  the  condition  was 
probably  congenital,  was  operated  on  recently  by  him  with  some 
benefit :  the  procedure  consisted  in  trephining  at  two  points  and 
removing  the  bridge  of  bone,  the  right  parietal  being  first  attacked, 
and  the  left  after  an  interval  of  about  a  month. 


IDIOCY   AND   IMBECILITY.  271 

"  The  operations  performed  by  Lannelongue  and  by  Keen  were 
more  extensive,  so  as  to  give  ample  room  for  expansion,  the  side 
of  the  head  being  made  into  a  bony  flap,  attached  below  and  free 
above.  Lannelongue  contented  himself  with  dealing  with  one 
side  only,  the  left ;  Keen  operated  on  the  right  side,  proposing  to 
attack  the  other  side  later  if  the  circumstances  should  seem  to  indi- 
cate such  a  course.  .  .  .  For  cosmetic  reasons.  Keen  made  his 
incision  of  the  skin  entirely  within  the  limits  of  the  hairy  scalp. 
...  It  seems  likely  that  the  initiative  thus  given  will  be  followed 
in  other  cases.  I  have  had  the  privilege  of  witnessing  two  of 
Keen's  operations,  and  the  procedure  is  certainly  a  brilliant  one,  of 
surprising  ease  in  skilled  hands."  * 

This  summer  I  treated  a  young  child  from  Texas  for  traumatic 
epilepsy.  At  the  time  of  my  first  examination  of  the  patient,  then 
between  six  and  seven  years  of  age,  I  found  an  ugly  scar  on  the 
left  side  situated  over  the  motor  area,  near  the  root  of  the  ascending 
frontal  convolution. 

At  the  age  of  two  and  a  half  the  child  sustained  a  serious  fall, 
of  from  ten  to  fifteen  feet,  striking  its  head  upon  some  loose  bricks 
at  the  point  where  I  found  the  scar.  The  boy  was  a  magnificent 
specimen  of  physical  development,  and  prior  to  the  traumatism 
was  learning  rapidly  to  speak  and  showed  unusual  intelligence. 
The  mother  told  me  that,  although  she  had  several  other  children 
who  were  quite  intelligent,  our  little  patient  was  before  the  fall  the 
brightest  member  of  the  family.  Immediately  after  that,  how- 
ever, convulsive  epilepsy  without  focal  symptoms  developed,  and 
the  child  became  deaf  and  mute.  All  hope  was  abandoned,  after 
protracted  treatment  by  many  eminent  physicians. 

In  consultation  with  my  friend  Dr.  H.  Tuholske,  professor  of 
surgery  in  the  Missouri  Medical  College,  an  exploratory  operation 
over  the  site  of  the  scar  was  determined  upon.  After  turning  back 
the  scalp  we  found  extensive  ossification  of  the  cranial  sutures, 
and  the  operation  of  trephining  was  abandoned.  A  month  later 
we  decided  upon  linear  craniotomy.  This  operation  was  per- 
formed in  December,  1891.  The  child  passed  safely  through  the 
dangers  attendant  upon  the  operation,  but  sufficient  time  has  not 
yet  elapsed  (January  15, 1892)  for  the  observation  of  any  definite 
results. 

*  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 


272  DISEASES   OF   THE   NERVOUS   SYSTEM. 

I  desire  to  report  in  this  place  another  ease  occurring  in  my 
practice  which  was  operated  upon  on  November  14, 1891,  by  Dr. 
Tuholske.  The  details  are  briefly  as  follows.  Parental  history 
good ;  first  and  only  child ;  anterior  fontanelle  small  at  birth  and 
entirely  closed  at  six  months.  The  child  did  not  use  its  hands 
like  other  babies,  could  not  sit  or  hold  up  the  head.  The  wrists 
were  constantly  flexed.  Sight  and  hearing  were  good.  There 
w'as  no  attempt  to  speak  ;  imbecility.  Operated  on  when  past 
two  years.  During  the  operation  the  chisel  was  abandoned  for 
Keen's  rongeur-forceps,  on  account  of  pronounced  symptoms  of 
concussion.  Healing  by  first  intention ;  left  hospital  two  weeks 
after  operation.  Dr.  Tuholske  tells  me  he  has  lately  heard  from 
the  mother  in  a  letter  dated  January  6,  1892.  She  reports  that 
marked  mental  and  physical  improvement  is  already  declared,  and 
gives  details  of  the  child's  condition  showing  this  to  be  the  case. 

I  must  tell  you  that  microcephalia  is  frequently  due  to  a  too 
abundant  supply  of  lime  salts,  as  where  drinking-water  is  highly 
charged  with  lime,  or  where  too  much  lime-water  is  added  to  the 
milk  of  bottle-fed  children ;  perhaps,  indeed,  it  is  almost  always 
due  to  some  such  cause,  except  where  chronic  inflammation  is 
plainly  the  originating  condition. 

One  more  form  of  insanity  to  be  considered  is 

MORAL   IMBECILITY. 

In  mental  imbecility  the  actions  express  a  want  of  activity  of 
the  higher  intellect,  but  in  moral  imbecility  there  is  an  absence  of 
the  manifestations  of  the  moral  intellect.  This  is  an  interesting 
psychological  condition. 

Have  you  never  at  school  seen  boys  expelled  who  had  no  idea 
of  moral  obligation,  conscience,  or  the  distinctions  between  meum 
and  tuum  f  who  were  constantly  in  "  hot  water,"  and  a  source  of 
anxiety  to  their  parents?  in  other  respects  intelligent  scholars, 
often  showing  mathematical  or  mechanical  talent,  but  always  lying 
or  stealing,  and  furthermore  given  to  voluptuous  and  intemperate 
tendencies  and  obscene  habits  ?  boys  who  would  forge  checks  to 
obtain  money ;  always  in  trouble  while  young,  and  under  the  eye 
of  the  police  when  grown  ;  although  belonging  to  good  families, 
with  every  advantage  of  education  and  religious  training,  they 
were  the  black  sheep  in  the  fold.     You  cannot  have  been  close 


KATATONIA.  273 

observers  if  you  have  not  seen  such  cases,  for  in  every  community 
you  may  find  numerous  instances.  A  boy  of  this  description  will 
be  as  much  trouble  to  the  family  physician  as  to  any  one  else,  as 
the  parents  will  be  unable  to  explain  his  actions,  being  averse  to 
thinking  him  insane,  on  account  of  his  being  so  bright  in  many 
respects. 

Such  is  moral  imbecility.  Such  people  have  the  misfortune  to 
be  born  and  grow  up  without  the  development  of  those  parts  of 
the  brain  which  preside  over  the  elaboration  of  the  moral  faculties, 
and  are  hence  a  source  of  mortification  to  their  relations  and  a 
curse  to  themselves. 

Some  authors  contend  that  moral  imbecility  may  be  congenital, 
or  maybe  acquired  as  a  result  of  disease  contracted  or  injuries  re- 
ceived during  childhood.  My  friend  Dr.  William  B.  Hazard,  now 
deceased,  once  related  to  me  the  case  of  a  boy  who  had  always 
shown  excellent  moral  tendencies  until  the  age  of  twelve  years, 
when  he  passed  through  a  severe  attack  of  typhoid  fever ;  after  his 
recovery  there  was  no  impairment  of  the  intellectual  faculties,  but 
there  was  such  a  decided  alteration  in  his  morals  that  his  parents 
were  firmly  convinced  that  during  his  sickness  he  had  become  the 
victim  of  demoniacal  possession. 

KATATONIA. 

Spitzka  defines  katatonia  "  as  a  form  of  insanity  characterized 
by  pathetical  emotional  state  and  verbigeration,  combined  with  a 
condition  of  motor  tension." 

It  was  first  described  by  Kahlbaura,  of  Gorlitz,  and  has  been 
more  recently  studied  by  Spitzka  and  Kiernan. 

It  usually  conmiences  with  symptoms  resembling  melancholia, 
which  are  followed  "  by  a  period  in  which  the  patient  presents 
an  almost  cyclical  alternation  of  atony,  excitement  of  a  peculiar 
type,  confusion,  and  depression,  which  finally  merge  into  a  state 
of  mental  weakness,  approaching  if  not  reaching  the  degree  of  a 
terminal  dementia.  Any  single  one  of  these  enumerated  phases 
may  be  absent." 

"  The  prognosis  of  katatonia  is  relatively  favorable  as  regards 
life,  although  the  danger  of  pulmonary  tuberculosis  developing  in 
the  depressed  and  atonic  stages  of  the  trouble  is  not  to  be  lost  sight 
of."     (Spitzka.) 

18 


274  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Folsom  states  that  in  katatonia  "■  there  is  an  underlying  well- 
marked  intellectual  impairment,  slowly  advancing  in  incurable 
cases  to  pronounced  dementia.  Delusions,  more  of  the  unsys- 
tematized than  of  the  systematized  character,  but  resembling  both, 
constitute  a  prominent  part  of  the  disease  from  the  beginning. 
Verbigeration  and  a  curious  sort  of  pomposity  are  usually  found 
in  more  or  less  pronounced  degree.  The  delusions  are  mixed. 
They  are  exalted,  hypochondriacal,  melancholic,  with  all  sorts  of 
self-accusation,  and  may  be  full  of  suspicion,  fears  of  poisoning, 
and  ideas  of  persecution.  Hallucinations  of  the  special  senses  and 
illusions  are  not  uncommon.  If  the  term  katatonia  is  not  used,  or 
at  least  if  a  special  place  in  the  nosology  were  not  given  this  dis- 
ease, it  would  be  difficult  to  know  whether  to  class  these  cases  as 
primary  dementia,  melancholia  with  delusions,  delusional  insanity, 
or  confusional  insanity." 

"  The  verbigeration,  when  it  exists,  and  the  expression  of  de- 
lusions are  often  associated  with  a  manner  on  the  part  of  the  patient 
suggesting  disbelief  in  them,  and  sometimes  the  patient  smiles  or 
laughs  at  the  astonishing  character  of  his  statements.  There  is  a 
self-conscious  element  at  times,  suggesting  mimicry  or  hysteria ; 
a  certain  pathos  is  universal ;  opposition  and  contradiction,  even 
to  refusal  to  eat,  leave  the  bed,  dress,  wash,  are  quite  common  ;  and 
nurse  and  physician  are  tired  out  with  the  monotony  of  the  mental 
and  physical  state.  Well-marked  catalepsy  is  not  common  in  my 
experience,  although  it  occurs;  and  in  all  cases  J.  have  seen  the 
mental  state  and  physical  atony  suggesting  that  condition.  Little 
attention  has  as  yet  been  given  to  katatonia  in  asylums  in  this 
country.  Judging  from  my  own  experience,  it  is  not  a  common 
disease."     (Folsom.) 

Prolonged  mental  exhaustion  and  syphilis  have  been  advanced 
as  probable  factors  in  the  production  of  katatonia. 

The  course  and  duration  of  the  disease  are  tedious,  with  tendency 
to  relapse  after  apparent  recovery. 

It  is  probably  a  neurosis ;  its  nature  is  quite  obscure. 

HYSTERICAL   INSANITY. 

Hysterical  insanity  is  more  frequent  among  women  than  among 
men.  Hysterical  symptoms,  as  I  stated  in  a  preceding  lecture, 
may  complicate  any  organic  or  functional  disease  of  the  nervous 


HYSTEKICAL   INSANITY.  275 

system ;  and  I  regard  it  as  very  doubtful  whether  a  distinctive 
form  of  insanity  termed  hysterical  is  entitled  to  a  nosological 
position. 

Folsom  asserts  that  "  it  is  characterized  by  extreme  and  rapid 
mobility  of  the  mental  symptoms, — amnesia,  exhilaration,  melan- 
cholic depression,  theatrical  display,  suspicion,  distrust,  prejudice, 
a  curious  combination  of  truth  and  more  or  less  unconscious  decep- 
tion, with  periods  of  mental  clearness  and  sound  judgment  which 
are  often  of  greater  degree  than  is  common  in  their  families ; 
sleeplessness,  distressing  and  grotesque  hallucinations  of  sight, 
distortion  and  perversion  of  facts  rather  than  definite  delusions, 
visions,  hypersesthesias,  anaesthesias,  parsesthesias,  exceeding  sen- 
sitiveness to  light,  touch,  and  sound,  morbid  attachments,  fanciful 
beliefs,  and  unhealthy  imagination,  abortive  or  sensational  suicidal 
manoeuvres,  occasional  outbursts  of  violence,  a  curious  combina- 
tion of  unspeakable  wretchedness  alternating  with  joy,  generosity 
and  selfishness, — of  gifts  and  graces  on  the  one  hand  and  exac- 
tions on  the  other.  The  mental  instability  is  like  a  vane  veered 
by  every  zephyr.  The  most  trifling  causes  start  a  mental  whirl- 
wind. There  is  no  disease  giving  rise  to  more  genuine  suifering 
or  appealing  more  strongly  for  the  sympathy  which,  freely  given, 
only  does  harm.  One  such  person  in  the  house  wears  out  and  out- 
lives one  after  another  every  healthy  member  of  the  family  who  is 
imwisely  allowed  to  devote  herself  with  conscientious  zeal  to  the 
invalid." 

The  prognosis  is  unfavorable. 

The  treatment  depends  largely  upon  mental  discipline  and  moral 
measures.  All  useless  sympathy  should  be  excluded.  Diversion, 
the  development  of  self-control,  and  general  hygienic  measures  are 
matters  of  the  most  essential  importance.  Never  was  better  pro- 
fessional advice  given  than  that  of  Folsom  when  he  states  that 
"  the  temptation  to  use  drugs  is,  like  the  fascination  of  being  pitied 
and  petted,  very  great,  as  alcohol,  chloral,  or  opium  often  acts  like 
magic  for  the  time  being,  and  there  is  a  general  craving  for  one 
or  all  of  them.  But  they  are  utterly  demoralizing  in  the  end. 
The  habitual  use  of  stimulants  and  narcotics  in  such  cases  only 
increases  the  evil.  The  fact  must  be  recognized  that  the  hysteri- 
cal insane  are  often  least  responsible  where  they  seem  most  so, 
and  that  they  must  be  treated  with  unending  patience,  kindness, 


276  DISEASES   OF   THE   NERVOUS   SYSTEM. 

gentle  firmness,  and  a  wise  ignoring  of  most  of  the  symptoms." 
I  have  found,  from  long  experience  that  the  salts  of  gold,  as 
originally  recommended  by  Niemeyer  in  hysteria,  are  very  val- 
uable. 

Weir  Mitchell's  "rest-cure"  will  frequently  produce  happy 
results. 

"  Cases  have  been  reported  of  two  persons  being  exposed  to  the 
same  causes  and  having  similar  attacks  of  insanity  {folie  a  deux), 
and  also  of  folie  induite  or  folie  communiquee,  where  several  per- 
sons have  adopted  the  delusions  of  a  person  of  influence  among 
them,  one  of  the  most  remarkable  instances  of  which  was  the  case 
of  the  seventeen  grammar-school-taught  Adventists  of  Pocasset, 
who  accepted  the  insane  belief  of  their  leader.  Freeman,  that,  like 
Abraham,  he  had  been  commanded  by  the  Lord  to  kill  his  child, 
that  she  was  to  rise  on  the  third  day  after  he  had  killed  her,  and 
that  he  was  to  become  a  great  evangelist.  So-called  epidemic 
insanity,  choreo-mania,  and  demonopathy  belong  in  this  class.  .  .  . 

"  From  untrained,  ill-balanced  men  and  women,  whose  lives  are 
ill  regulated,  the  ranks  of  the  insane  are  largely  filled.  Insanity 
is  often  the  ultimate  wreck  of  a  life  ill  guided,  directed  chiefly  by 
caprice  and  passion,  and  weakened  by  indulgence.  In  that  case  it 
is,  much  like  habitual  drunkenness,  as  much  a  fault  as  a  disease. 
The  individual  will  not  behave  with  decency  and  propriety  for  so 
long  a  time  that  finally,  especially  after  the  age  when  the  brain 
begins  to  fail,  he  cannot."     (Folsom.) 

TRANSITORY   INSANITY. 

"  Th^anntory  insanity  is  used  by  Kraift-Ebing  as  indicating 
mental  disease  differing  from  other  insanity  only  in  the  fact  that 
it  is  of  short  duration, — namely,  from  two  to  six  days.  If  it  is 
applied  to  sudden  and  transient  outbursts  of  mania,  with  delirium, 
loss  of  power  of  self-control,  and  inability  to  clearly  recollect  the 
circumstances  of  the  attack  and  what  happened  during  its  con- 
tinuance, it  is  a  rare  disease,  occurring  for  the  most  part  in  epilep- 
tics and  in  persons  under  the  influence  of  alcohol  or  addicted  to 
its  habitual  use.  It  is  sometimes  under  the  latter-named  condition 
called  alcoholic  trance.  It  consists  in  an  automatic  state  resem- 
bling the  epileptic  delirium,  which  may  occur  also  in  sleep  and 
resembles  somnambulism.     The  actions  are  guided  by  co-ordinated 


ALCOHOLIC   INSANITY.  277 

will  without  conscious  intelligence,  and  may  consist  in  crimes  and 
brutalities  and  foolishness  entirely  inconsistent  with  the  character 
in  health.  It  seldom  lasts  more  than  a  few  hours.  When  caused 
by  alcohol  or  as  a  symptom  of  epilepsy,  it  may  occur  without  other 
marked  inciting  cause  ;  otherwise  it  is  commonly  due  to  mental 
shock.  Several  cases  happened  during  the  mental  excitement  of 
the  first  battle  in  our  civil  war.  The  most  striking  case  within 
my  own  experience  was  that  of  a  man  who  under  the  strain  of 
prolonged  grief  and  the  mental  shock  of  a  great  fire  destroying 
a  large  part  of  the  town  in  which  he  lived,  perhaps  moderately 
affected  by  alcohol,  suddenly  grasped  an  axe  and  cut  off  with  one 
blow  the  head  of  a  beloved  child.  He  was  found  in  the  street 
without  knowing  how  he  had  got  there  or  what  he  had  done.  One 
attack  is  the  rule,  although  several,  probably  of  an  epileptic  nature, 
have  been  reported.  It  is  an  extremely  difficult  condition  to  diag- 
nosticate with  certainty,  and  is  therefore  often  the  refuge  of  crim- 
inals and  a  resource  of  criminal  lawyers.  The  most  likely  honest 
mistake  liable  to  be  made  regarding  it  is  to  confound  it  with  an 
outburst  of  passion."     (Folsom.) 

The  above  views,  I  must  confess,  are  not  altogether  in  accord- 
ance with  my  own  impressions.  All  cases  of  transitory  insanity, 
in  my  opinion,  are  of  epileptic  origin,  and  if  the  histories  of  the 
above  cases  were  carefully  scrutinized,  I  think  it  almost  certain 
tliat  they  would  lead  back  to  such  a  condition. 

Alienists  and  medical  experts  should  be  careful  not  to  give  too 
much  latitude  to  the  plea  of  insanity  in  cases  like  these,  unless 
epilepsy  be  clearly  recognized  and  proved  ;  otherwise  the  extraor- 
dinary and  absurd  verdict  rendered  in  the  case  of  General  Cole, 
of  New  York,  may  be  repeated, — namely,  "  Sane  one  moment  prior 
to  the  homicide,  insane  during  the  homicide,  and  sane  one  moment 
after.'''  Such  a  plea  in  a  criminal  case  based  upon  the  questionable 
theory  of  "  transitory  insanity"  (without  epileptic  complications)  is 
a  prostitution  of  medical  expert  testimony. 

ALCOHOLIC    INSANITY. 

Under  this  designation  we  include  "  mental  disorder  from  the 
use  of  alcohol  in  both  the  acute  and  chronic  forms. 

"Acute  alcoholic  mania  may  be  caused  by  a  single  excess  in 
drinking,  which  in   some  individuals   is   always   attended  with 


278  DISEASES   OF   THE   XEEVOUS  SYSTEM. 

maniacal  symptoms.  It  may  constitute  the  alcoholic  trance  de- 
scribed under  the  head  of  transitory  insanity.  From  long  drink- 
ing and  exhaustion  or  by  withdrawal  of  the  accustomed  stimulant 
we  may  have  the  familiar  mania-a-potu,  or  delirium  tremens." 
(Folsom.) 

"  To  the  prolonged  use  of  alcohol,  primary  delusional  insanity, 
melancholia,  mania,  and  dementia  are  often  due.  From  continued 
alcohol-drinking,  even  in  but  slight  excess,  during  many  years,  it 
is  rare  that  some  mental  impairment  does  not  become  evident,  if 
only  an  '  uncontrollable  violence  of  the  instincts  and  emotions,'  a 
sort  of  moral  insanity.  .  .  .  The  prognosis  is  more  favorable  than 
in  most  forms  of  insanity  uncomplicated  by  the  abuse  of  alcohol, 
especially  in  cases  of  primary  delusional  insanity,  if  the  bad  habits 
can  be  effectually  corrected  and  if  the  alcoholic  excesses  have  not 
been  continued  long  enough  to  produce  organic  changes  in  the 
cerebral  blood-vessels.  In  the  latter  case  the  dementia  sometimes 
simulates  that  of  general  paralysis  so  closely  as  to  be  called  pseudo- 
paralytic dementia  from  alcohol." 

"Chronic  alcoholic  insanity  depends  upon  the  vascular  and  other 
changes  due  to  abuse  of  alcohol  so  long  continued  that  the  patho- 
logical condition  has  become  org^anic  and  incurable.  It  is  com- 
monly associated  with  delusions  or  suspicions  of  persecution.  It 
may  be  a  purely  moral  insanity,  with  gross  beliefs  rather  than 
distinctly  insane  delusions,  and  it  rarely  fails  to  be  at  least  that 
when  the  persistent  excessive  drinking  is  kept  up  until  the  age  of 
beginning  dissolution  of  the  brain.  It  then  gives  rise  to  all  sorts 
of  embarrassing  complications  in  regard  to  property,  family  rela- 
tions, and  wills.  Chronic  alcoholic  insanity  may  take  the  form  of 
mild  dementia,  by  virtue  of  which  the  patient  cannot  control  him- 
self, but  can  be  easily  kept  within  bounds  of  reasonable  conduct 
by  various  degrees  of  restraint,  from  the  constant  presence  of  a 
responsible  person  to  the  seclusion  of  an  asylum.  In  well-marked 
cases  this  dementia  is  associated  with  muscular  weakness,  tremor, 
and  exhilaration  to  such  an  extent  as  to  simulate  general  paralysis. 
It  is  then  called  by  some  (especially  the  French)  writers  pseudo- 
pa7'alytic  dementia  from  alcohol.  The  condition  is  susceptible  of 
improvement  by  removal  of  the  cause,  alcohol,  and  by  a  carefully- 
regulated  life,  hydropathic  treatment,  etc.,  but  complete  recoveries 
cannot  be  expected."     (Folsom.) 


INSANITY   AND   BRIGHT's   DISEASE.  279 


INSANITY   AND   BRIGHT'S   DISEASE. 

Alice  Bennett,  in  an  article  on  "Insanity  as  a  Symptom  of 
Briglit's  Disease,"  says,  "  Briefly  formulated,  my  experience  has 
led  me  to  believe :  (1)  That,  contrary  to  the  generally  received 
opinion,  affections  of  the  kidney  are  very  common  among  the 
insane.  (2)  That  '  ursemic  poisoning'  is  one  of  the  most  frequent 
causes  of  insanity.  (3)  That,  while  the  mental  manifestations 
may  be  as  varied  as  there  are  different  centres  subjected  to  irrita- 
tion by  these  unknown  poisons,  the  most  prominent  and  constant 
symptom  is  some  form  of  mental  pain,  which  may  range  from 
simple  depression,  through  all  degrees  and  varieties  of  delusions 
of  persecution,  self-condemnation,  and  apprehension,  with  or  with- 
out hallucinations,  up  to  a  condition  characterized  by  a  frenzy  of 
fear,  with  extraordinary  motor  excitement  and  rapid  physical  pros- 
tration,— the  '  grave  delirium'  or  '  typho-mania'  of  some  authors. 
(4)  That  the  motor  centres  are  specially  liable  to  affection,  as 
evidenced  by  the  restlessness  and  incessant  activity  of  many 
cases,  less  frequently  by  convulsions  and  convulsive  twitchings, 
occasionally  by  choreic  movements,  occasionally  by  cataleptoidal 
states." 

"  I  fear  that  Dr.  Bennett  will  not  be  generally  supported  in  such 
a  confession  of  faith.  We  may  venture  to  affirm  that  as  many 
cases  of  kidney-disease  will  be  found  in  the  ranks  of  our  usual 
patients  as  among  the  insane,  excluding  general  paretics.  I  have 
made  this  point  a  subject  of  careful  attention  for  some  years, 
and  I  have  not  observed  the  proportion  of  kidney-lesions  which 
Dr.  Bennett  appears  to  have  done.  In  the  few  cases  of  '  grave 
delirium'  which  have  come  under  my  care  this  point  has  been 
especially  watched,  but  with  negative  results,  as  likewise  in  the 
majority  of  instances  of  mental  depression  and  anxiety. 

"  I  recognize  the  merits  of  Dr.  Bennett's  contribution,  not  the 
least  of  which  is  the  emphasis  which  she  puts  upon  the  fact,  before 
an  audience  of  general  practitioners,  that  insanity  is  a  symptom 
the  explanation  of  which  must  be  looked  for  in  some  disturbance 
of  the  general  physiological  functions."* 

*  Brush,  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 


280  DISEASES  OF  THE   NERVOUS  SYSTEM. 

"insanity    following   INFLUENZA. 

"Recent  epidemics  of  influenza  have  been  followed  by  numerous 
cases  of  insanity,  and  a  few  cases  have  been  narrated  of  recovery 
apparently  hastened  by  an  attack  of  the  epidemic.  Metz  narrates 
a  recovery  from  paranoia.  Febrile  delirium  during  an  infectious 
disease  is,  in  fact,  an  acute  attack  of  insanity.  There  are  the  feb- 
rile mental  derangements  proper  to  the  fever  (psychoses  febriles), 
and  there  is  the  delirium  of  convalescence  (psychoses  astheniques). 
The  latter  embraces  many  distinct  kinds.  Towards  the  end  of  acute 
infectious  diseases  there  is  the  '  delirium  of  inanition/  which  may 
go  on  to  the  delirium  of  collapse,  so  well  described  by  AVeber.  But, 
though  asthenic  delirium  is  the  most  common  kind  during  con- 
valescence (Christian),  other  kinds  are  met  with,  sensorial  delusions 
being  often  jsresent.  There  is  probably,  in  such  cases,  a  cerebral 
intoxication  due  to  microbic  products  of  the  virus  which  has  set 
up  the  disease.  One  great  distinction  between  the  psychoses  of 
convalescence  and  the  delirium  of  fever  lies  in  the  evident  influence 
of  heredity  and  the  personal  antecedents  of  the  patient  upon  the 
character  of  the  delirium  in  the  former  case  (Krapelin,  Savage), 
in  contrast  to  its  uniform  course  in  the  latter ;  in  fact,  heredity 
appears  to  play  the  chief  part,  and  the  acute  disease  is  often  only 
the  accidental  cause  of  the  mental  alienation.  The  diseases  most 
frequently  followed  by  the  latter  are :  acute  rheumatism,  pneu- 
monia, small-pox,  intermittent  fever,  typhoid  fever,  cholera,  and 
erysipelas ;  more  rarely  angina  and  scarlet  fever,  and  very  rarely 
measles  and  whooping-cough.  As  to  influenza,  the  psychoses  which 
may  follow  it  were  scarcely  ascertained  before  the  last  great  pan- 
demic. Petrequin,  who  described  the  epidemic  of  1837,  only  cites 
Rush,  of  Philadelphia,  and  Bonnet,  of  Bordeaux.  The  former 
says,  '■  several  persons  who  were  affected  by  it  had  symptoms  of 
madness,  one  of  whom  destroyed  himself  by  jumping  out  of  a 
window.'  Bonnet  reports  a  case  of  furious  mania  after  influenza 
during  the  epidemic.  Crichton-Browne  gives  a  case  of  acute 
dementia  after  the  influenza  of  1874. 

"  Revilliod,  of  Geneva,  has  studied  the  nervous  forms  of  '  la 
grippe,'  and  has  shown  that  delirium  may  be  the  first  symptom, 
as  in  other  acute  diseases.  ... 

"  Krapelin  gives  two  cases  of  typical  delirium  tremens  after  in- 


INSANITY   COMPLICATING   HEAET-DISEASE.  281 

fluenza,  the  author  one.  Medico-legal  questions  have  arisen  out 
of  the  mental  derangements  of  convalescence  from  acute  diseases. 
Murders  and  other  criminal  acts  have  been  committed,  especially 
after  intermittent  fever.  Thus  influenza,  like  other  acute  diseases, 
may  be  the  last  stroke  in  developing  an  attack  of  insanity  the 
kind  of  which  is  altogether  independent  of  influenza.  Even 
general  paralysis  has  followed  it.  Influenza  in  itself  never  causes 
insanity.  [Brush  goes  on  to  explain  that  an  enfeebled  system,  the 
influence  of  heredity,  and  the  personal  antecedents  of  the  patient 
are  correlated  facts  of  great  importance.] 

"  Lastly,  la  nonna  is  a  grave  nervous  form  of  mental  sequelce 
of  influenza.  ...  At  Zozzoi  di  Sorramontane  ten  persons  are 
said  to  have  died  of  la  nonna  within  a  few  hours.  Pagello  and 
Murer,  who  officially  examined  into  this  matter,  found  that  they 
died  of  a  sort  of  '  exanthematous  miliary  contagious  fever,' — a 
comprehensive  term.  They  also  declared  that  not  one  of  the 
patients  had  died  within  a  few  hours  :  even  the  most  rapid  cases 
had  lasted  at  least  two  days.  The  Vienna  physicians  consider  la 
nonna  as  an  asthenic  psychosis,  ending  in  lethargy  and  coma,  occur- 
ring, for  the  most  part,  in  persons  overworked  and  exhausted  in 
every  way,  who  have  not  been  able  to  attend  to  themselves  during 
the  influenza.  The  Italian  word  nonna,  literally  grandmother,  may 
also  be  translated  old  woman  or  so7'ceress.  Now,  there  is  a  well- 
known  legend  that  when  a  sorceress  touches  a  sick  person  with  the 
end  of  the  finger  he  will  surely  die.  The  power  of  auto-sugges- 
tion is  now  sufficiently  known,  and,  in  a  superstitious  country,  such 
beliefs  must  occasionally  have  sad  consequences,  especially  among 
convalescents  from  a  depressing  disease  like  influenza."  * 

"  The  prognosis  of  all  these  psychoses  is  usually  favorable,  and 
the  treatment  is  self-evident :  it  should  be  strengthening  in  every 
sense  of  the  term,  and  also  soothing." 

INSANITY   COMPLICATING   HEART  DISEASE. 

As  to  the  alleged  fact  that  valvular  disease  of  the  heart  is  regarded 
by  some  writers  as  a  frequent  cause  of  depressed  emotional  con- 
ditions, I  fully  agree  with  Spitzka,  who  states,  "  When,  however, 
we  remember  the  large  number  of  persons  whose  hearts  are  in  the 

*  Brush,  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 


282  DISEASES   OF   THE   NERVOUS   SYSTEM. 

most  extreme  conditions  of  organic  failure,  and  who  die  in  conse- 
quence, but  without  having  manifested  any  special  psychical  dis- 
order, we  will,  when  we  discover  a  fixed  delusion  of  persecution 
in  a  subject  with  aortic  obstruction,  look  for  some  other  cause, 
such  as  an  insane  predisposition  or  mental  overstrain,  as  the  pri- 
mary determining  element,  while  the  cardiac  disorder  may  be  ad- 
mitted to  act  as  an  exciting  cause,  or,  more  accurately  speaking, 
to  determine  the  anxious  or  suspicious  character  of  a  delusion. 
It  is  a  fact  that  patients  suffering  from  cardiac  lesions  are  more 
likely  to  develop  anxious  and  suspicious  delusions  than  those  of 
an  opposite  nature." 

Spitzka  quotes  Emminghaus,  as  follows :  "  In  two  cases  of 
Basedow's  disease  (exophthalmic  goitre)  he  found  pronounced 
mental  disturbance  in  the  shape  of  melancholia  and  periodical 
mania.  The  occasional  occurrence  of  this  disorder  in  members 
of  families  afflicted  with  a  morbid  heredity  would  seem  to  indicate 
that  the  physical  disease  and  the  insanity  are  simply  collaterals, 
and  that  both  are  the  expressions  of  the  same  fundamental  neurotic 
vice.  It  is  an  interesting  problem  for  the  future  to  solve  why 
enlargement  of  the  thyroid  gland  should  in  two  disorders  such 
as  exophthalmic  goitre  and  cretinism  be  associated  with  mental 
disorder  or  defect." 

In  answer  to  Spitzka,  I  would  suggest  that  Schroeder  van  der 
Kolk,  to  my  mind,  very  satisfactorily  solves  this  problem  as  fol- 
lows :  "  Therefore,  without  prejudice  to  other  functions  which  are 
possibly  also  intrusted  to  it,  the  thyroid  may  be  regarded  as  a 
diverticulum  or  reservoir  by  which  a  too  strong  pressure  of  blood 
may  be  diverted  from  the  brain.  Moreover,  the  position  of  the 
origin  of  the  thyroidea,  in  proximity  to  the  vertebralis  and  carotis 
interna,  yet  gains  in  significance  as  this  arrangement  is  not  limited 
to  the  mammalia.  For  according  to  J.  Simon  (On  the  Comparative 
Anatomy  of  the  Thyroid  Gland,  in  Phil.  Transact,  1844,  page 
295),  the  thyroidese  of  the  bird  arise  exactly  opposite  the  place 
where  the  carotid  and  vertebral  come  off,  and  even  in  amphibia  and 
fishes  these  vessels  stand  in  relation  with  the  vessels  of  the  brain. 

"  From  this  it  becomes  not  improbable  that  the  presence  of  a 
goitre,  which  receives  a  great  deal  of  blood,  and  which  may  derive 
too  powerfully  from  the  brain,  induces  in  cretins  a  weaker  develop- 
ment of  the  brain,  or,  at  least,  a  debilitated  energy  of  it,  although 


INSANITY   COMPLICATING  HEART-DISEASE.  283 

cretinism  is  not  to  be  regarded  as  a  product  of  the  goitre,  but  only 
appears  to  be  frequently  present  with  it.  It  might  also  in  this 
■way  be  explained  why  individuals  who  are  afflicted  with  goitre  for 
the  most  part  are  not  very  lively  and  active,  but  appear  to  be  more 
phlegmatic.  It  may  also  be  connected  herewith  that  I  have  some- 
times, in  meningitis  chronicft  and  meningitis  idiopathica,  found  a 
small  indurated  yellow-tinged  thyroid  gland,  because  through  this 
condition  the  derivation  of  the  blood-stream  from  the  brain  would 
be  impeded,  which  then  led  to  repeated  congestions  and  contrib- 
uted to  the  development  of  meningitis.  I  should  at  least  wish 
this  point  to  be  regarded  in  future  examinations." 


LECTURE    XYII. 

EPILEPTIC   IXSANITY   ANT)   ITS   MEDICO-LEGAL,   RELATIONS. 

Gentlemen, — It  is  only  of  late  years  that  epilepsy  has  received 
at  the  hands  of  writers  upon  forensic  medicine  the  attention  which 
its  importance  demands.  In  the  criminal  records  of  civilized 
countries  but  few  cases  will  be  found  in  which  this  common  affec- 
tion has  been  duly  considered  in  fixing  the  responsibility  of  the 
accused,  while  in  many  instances  but  small  appreciation  has  been 
shown  of  the  grave  questions  involved  in  the  study  of  epilepsy, — 
a  disease  of  most  changeful  aspect  and  easily  misunderstood. 

The  older  cases  of  Tyler,  Bethel,  and  Winnemore,  discussed  in 
Dr.  Ray's  great  work  upon  "  The  Medical  Jurisprudence  of  In- 
sanity," bear  witness  to  the  fact  of  jurisconsult  ignorance  respecting 
this  disease,  even  at  a  comparatively  recent  period  ;  while  the  later 
cases  of  ]\Iax  Klingler  and  David  Montgomery  show  how  great 
lias  been  the  advance  of  a  portion,  at  least,  of  the  medical  profes- 
sion in  knowledge  of  the  affection,  and,  at  the  same  time,  the  slow 
pace  at  ^^vhich  the  legal  follows  the  medical  mind  where  questions 
of  criminal  responsibility  are  involved. 

We  concur  fully  in  Spitzka's  opinion,  that  when  the  medical 
or  legal  relations  of  epilepsy  and  epileptic  insanity  are  discussed 
by  authors,  they  confine  their  attention  too  exclusively  to  three  cate- 
gories,— "  first,  to  the  condition  called  epileptic  mania ;  secondly, 
to  epileptic  dementia  ;  and,  thirdly,  to  the  peculiar  change  of 
character  which  many  epileptics  manifest." 

Spitzka  particularly  insists  that  these  phases  fail  to  include  many 
important  conditions  allied  to  epilepsy  and  dependent  upon  it,  and 
which,  moreover,  may  require  special  medical  treatment  and  de- 
mand the  serious  attention  of  every  thorough  and  conscientious 
medical  jurist. 

This  author  also  remarks  that  it  is  an  opinion  quite  prevalent 
with  many,  that,  except  for  the  period  just  preceding  and  following 
284 


EPILEPTIC  INSANITY  AND   ITS  MEDICO-LEGAL  RELATIONS.      285 

the  attack,  and  included  in  it,  an  epileptic,  if  not  chronically  de- 
mented, is  always  sane  from  a  medical,  and  competent  and  respon- 
sible from  a  medico-legal,  aspect.  This  view,  he  asserts,  is  held 
by  many  general  jDractitioners  and  by  most  English  medico-legal 
writers.  On  the  other  hand,  he  observes  that  certain  examiners, 
as  soon  as  they  determine  the  slightest  indications  of  epilepsy, 
instantly  conclude  that  the  subject  cannot  be  of  sound  mind  or 
responsible  for  any  action  whatsoever.  This  view  he  regards  as 
peculiar  to  those  who  are  frequently  called  in  by  the  defence,  where 
a  plea  of  insanity  is  the  last  resort  of  the  defendant.  Both  views, 
he  states,  constitute  utterly  erroneous  extremes,  and  not  erroneous 
only,  but  also  damaging  to  the  cause  of  justice,  inasmuch  as  inter- 
ested or  even  unscrupulous  medical  witnesses  have  been  able  to 
fortify  themselves  by  such  opinions  drawn  from  published  works, 
in  support  of  testimony  too  often  successful  in  defeating  the  legiti- 
mate purposes  of  the  law. 

I  believe  that  most  writers  on  this  subject  are  prone  to  adopt 
extreme  views.  "  Virtus  slat  in  medioj'  In  the  investigation  of 
disputed  scientific  problems,  especially  those  of  a  disease  so  occult, 
intricate,  and  variable  as  epilepsy,  a  wise  conservatism  is  a  more 
judicious  and  a  safer  guide. 

We  can  scarcely  in  this  matter  go  so  far  as  to  affirm  with  J.  B. 
Friedreich,  of  Bavaria,  a  noted  German  authority,  that  '^  Criminal 
responsibility  is  absent  in  epileptics,  even  should  it  be  proved  that  the 
determination  to  commit  a  criminal  action  resulted  from  revenge  or 
malignity." 

On  the  contrary,  I  believe  that  Trousseau  is  nearer  the  truth 
when,  in  speaking  of  the  criminality  of  epileptics,  he  uses  the 
following  strong  language  :  "  It  may  be  said,  almost  without  fear  of 
making  a  mistake,  that  if  a  man  suddenly  commits  murder,  without 
any  previous  intellectual  disturbance,— without  having,  up  to  that 
time,  shown  any  symptoms  of  insanity,  and  if  not  under  the  influence 
of  passion,  or  of  alcohol,  or  of  any  other  jioisonous  substance  which 
acts  with  energy  on  the  nervous  system, — it  may  be  said,  I  repeat,  that 
the  man  is  afflicted  with  epilepsy,  and  that  he  has  had  a  fit,  or,  more 
usually,  an  attack  of  epileptic  vertigo^ 

Again,  says  the  same  author,  "  Who  can  calculate  the  degree  of 
liberty  possessed  by  a  man  in  this  state  of  transition  between  the 
actual  attack  and  the  complete  recovery  of  his  mental  faculties  ? 


286  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Is  there  a  medical  man  bold  enough  to  pronounce  on  this  point,  and 
to  a^nn  that  a  crime  committed  after  the  attach  must  entail  respon- 
sibility f 

According  to  Esquirol,  the  return  of  reason  after  epileptic  seiz- 
ures ma}'  sometimes  manifest  itself  immediately  after  an  attack, 
Avhile  in  other  cases  it  does  not  appear  for  several  hours,  or  even 
days.  Hallucinations,  more  or  less  permanent,  may  complicate 
epilepsy,  and  thereby  become  a  source  of  dangerous  impulses.  It 
is  known  that  when  under  rare  conditions  a  threatened  attack  of 
epilepsy  has  been  averted,  its  suppression  in  some  instances  occa- 
sions such  painful  and  insupportable  agitation  as  to  cause  some 
of  the  unfortunate  victims  of  this  aifection  to  indulge  excessively 
in  alcoholic  liquors,  or  to  seek  an  occasion  of  quarrel  by  means  of 
which  to  give  vent  to  their  ])ent-up  irritability,  and  thereby  to 
relieve  excessive  nervous  tension,  as  an  impatient  hysterical  woman 
does  when  she  screams,  stamps  her  foot,  or  falls  into  convulsions. 
Esquirol,  when  classifying  the  epileptic  manifestations  of  three 
hundred  and  thirty-nine  patients  thus  afflicted,  who  were  under 
his  care,  speaks  of  some  who  have  "  un  delire  fugace,"  and  again 
"  soixante  n'ont  aucune  aberration  de  I'intelligence,  mais  elles  sont 
d'une  tres-grande  susceptibility,  irascibles,  entetees,  difficiles  a  vivre, 
eapricieuses,  bizarres ;  toutes  ont  quelque  chose  de  singulier  dans 
le  caractere."  Epileptic  vertigo  is  more  destructive  to  the  intellect 
than  convulsive  seizures.  Its  duration  is  often  inappreciable,  and 
so  slight,  occasionally,  are  its  manifestations,  that  persons — even 
medical  men — who  are  not  expert  may  readily  fail  to  recognize  it, 
• — a  fact  of  great  importance,  as  we  shall  find  further  on.  In  de- 
scribing the  desperate  and  dangerous  seizures  of  epileptic  fury, 
Esquirol  observes,  "  Cette  fureur  est.  si  redoutable  et  si  redout^e 
que  j'ai  vu  un  hospice  du  Midi  ou  tons  les  ^pileptiques  ^taient  en- 
chaines  chaque  soir  sur  leur  lit,  par  la  crainte  qu'ils  inspiraient." 

It  is  much  to  be  regretted  tliat  a  fashion  prevails  at  the  present 
day  of  attempting  to  shield  cnminals  under  the  protective  aegis  of 
a  plea  of  insanity.  This  plea  is  too  often  set  up  to  defeat  the  ends 
of  justice  and  in  extenuation  of  most  fearful  crimes.  Insanity 
is  a  well-recognized  cause  of  impulsive  crime,  and  a  suspicion  of 
its  existence  should  incite  great  care  and  the  most  elaborate  re- 
search in  dubious  cases,  but  the  fact  that  such  a  possibility  of 
insanity  is  too  frequently  urged  should  not  so  affect  public  opinion 


EPILEPTIC  INSANITY  AND   ITS  MEDICO-LEGAL  EELATIONS.     287 

as  to  render  punishment  inevitable  to  fellow-creatures  unfortunate 
enough  to  be  morally  irresponsible.  Christian  charity,  or  even 
common  humanity,  should  make  us  at  least  fair  and  just  in  our 
dealings  with  this  class  of  criminals,  whose  dark  and  frightful 
deeds  are  only  results  of  a  paralysis  of  that  will-power  which 
alone  makes  man  a  free  and  responsible  agent.  Less  than  this 
philanthropy  cannot  ask,  and  it  were  better  that  many  guilty 
should  escape  than  that  one  innocent  man  should  unwarrantably 
suffer  the  extreme  penalty  of  the  law. 

The  disastrous  influence  of  epilepsy  upon  the  intellectual  facul- 
ties is  denied  by  the  eminent  author  J.  Russell  Reynolds,  as 
follows :  "  A  prevalent  belief  is  that  some  form  or  degree  of 
mental  deterioration  is  necessarily  associated  with  epilepsy.  The 
result  of  inquiry  upon  this  point  is  to  show  that  there  is  no  such 
'necessary'  relation.  The  general  belief  is,  however,  to  be  ac- 
counted for  partly  by  the  strong  impression  which  some  notable 
cases  of  mental  failure  have  made  upon  the  minds  of  those  who 
witnessed  and  recorded  them, — such  strong  impression  being  fol- 
lowed by  an  undue  inference, — and  partly  by  the  fact  that  the 
words  '  epilepsy^  and  '  epileptic^  have  been  made  to  include  every 
form  of  disease  of  brain,  spinal  cord,  or  other  organs  which  might 
be  associated  with  fits,  and  also  every  variety  of  that  multiform 
derangement  which  we  call  'insanity  of  mind.'  It  is  desirable, 
again,  to  assert  that  this  article  refers  only  to  such  cases  as  con- 
stitute epilepsy  proper,  and  that  the  statistics  upon  which  my 
results  are  based  can  only  with  a  double  injustice  be  compared 
with  those  derivable  from  lunatic  asylums.  A  patient  may  be 
epileptic  and  a  lunatic ;  he  may  be  epileptic  and  an  asthmatic ; 
but  there  are  some  epileptics  whose  minds  are  as  healthy  as  their 
lungs  ;  and,  so  far  as  the  natural  history  of  epilepsy  generally  is 
concerned,  it  is  a  mistake  to  derive  it  from  complicated  cases."  * 

Notwithstanding  these  ingenious  statements,  I  must  tell  you 
that  the  fatal  influence  of  epilepsy  upon  the  intellectual  faculties, 
and  especially  of  epileptic  vertigo,  is  only  too  familiar  to  attentive 
and  unprejudiced  observers. 

In  many  individuals  of  apparently  perfect  intellectual  activity 
and  organization,  "  a  singular  changeableness  of  feeling,  of  temper, 

*  Keynolds,  article  "  Epilepsy,"  System  of  Medicine,  vol.  ii.,  1868. 


288  DISEASES   OF   THE   NERVOUS   SYSTEM. 

and  of  character,  violent  fits  of  passion,  which  they  cannot  master, 
point  to  a  particular  mental  condition  which  in  the  greater  number 
of  cases  will  be  followed  by  physical  phenomena  of  a  more  distinct 
character,  but  always  of  the  same  order,  as  well  as  by  more  serious 
cerebral  disorders,  such  as  attacks  of  delirium,  sometimes  transient, 
sometimes  prolonged,  and  then  specially  deserving  the  name  of  epi- 
leptic insanity.  These  disorders  of  an  intellectual  character  may 
occur  in  the  intervals  between  the  epileptic  paroxysms,  may  occur 
immediately  before  or  after  the  attack,  or  they  may  be  more  or  less 
prolonged,  connected  with,  or  occurring  independently  of,  the 
attack,  and  are  then  more  particularly  characteristic  of  epileptic 
insanity."  Such  individuals  are  unquestionably  subject,  during 
the  interval  between  convulsive  attacks,  to  "  a  particular  mental 
phase,"  quite  significant  as  to  certain  tendencies  and  consequences. 
These  patients  are  sometimes  querulous  and  prone  to  acts  of  vio- 
lence or  explosive  manifestations  of  the  most  terrific  rage  and 
sanguinary  fury.  Trousseau,  in  his  admirable  "  Study  of  Epi- 
lepsy," quoting  Jules  Falret,  says,  "This  irregularity  in  the  state 
of  their  feelings  and  the  degree  of  their  intelligence  is  necessarily 
reflected  in  their  talk  and  in  their  acts.  Hence  the  excessive 
variability  of  their  behavior  towards  those  about  them.  For  a 
certain  period  of  their  lives  they  are  laborious,  punctual,  attentive 
to  the  duties  of  their  profession,  obedient  and  docile,  and  those 
who  live  with  them,  or  who  employ  them,  find  their  intercourse 
agreeable,  or  are  pleased  with  their  services.  But  at  other  times 
their  conduct  becomes  suddenly  modified,  and  presents  the  greatest 
irregularities.  They  are  then  incapable  of  fulfilling  their  duties, 
become  negligent,  lazy,  and  indolent.  They  forget  the  most  ele- 
mentary things,  waste  their  time  or  wander  here  and  there  without 
aim  or  object  in  view,  and  are  themselves  conscious  of  the  vague- 
ness and  confusion  of  their  ideas.  The  most  deplorable  tendencies 
and  the  worst  inclinations  develop  themselves  in  them  at  the  same 
time  ;  they  become  liars  and  thieves ;  they  pick  quarrels  laith  those 
around  them,  complain  of  everything  and  of  everybody,  are  very 
easily  irritated  for  the  slightest  cause,  and  even  frequently  commit 
sudden  acts  of  violence,  which  in  most  cases  have  not  the  excuse  of 
provocation  on  the  part  of  the  victims  of  these  acts." 

The  existence  of  "epileptic  delirium,"  a  condition  somewhat 
allied  to  somnambulism,  where  the  patient  is  not  always  totally 


EPILEPTIC  INSANITY  AND  ITS  MEDICO-LEGAL  RELATIONS.     289 

unconscious,  as  he  is  during  the  more  common  epileptic  seizures, 
but  has  a  vague  and  dreamy  sense  of  his  condition  and  of  pass- 
ing events,  is  fully  recognized  by  our  most  reliable  authors.  The 
j)erceptive  faculties  may  be  unaffected,  but  the  higher  intellectual 
faculties  and  the  will  are  not  exerted,  or  are  so  only  automatic- 
ally. The  actions  of  the  patient  are  to  a  great  extent  instinctive, 
or  in  some  instances  purely  automatic.  These  attacks  hold  "  an 
intermediate  place  between  simple  epileptic  vertigo  and  the  con- 
vulsive fits."  It  is  not  difficult  to  appreciate  the  existence  of  in- 
stinctive actions,  or  even  of  actions  springing  from  a  still  more 
subordinated  source,  or  indeed  of  a  purely  perceptive  origin.  Ideas 
are  purely  mental  operations,  and  must  be  held  to  originate  in  the 
cortical  structure  of  the  cerebral  convolutions.  That  "mere  sen- 
sation and  apparent  volition  may  exist  independently  of  intellectual 
action,  and  even  after  the  cerebrum  has  been  destroyed,"  is  an  al- 
legation of  physiological  psychology.  Apparent  volition  without 
higher  and  more  developed  intellectual  elaboration,  by  which  an 
act  is  accomplished  without  the  obvious  concurrence  and  approval 
of  the  judgment,  and  without  the  co-operation  of  an  active  intel- 
ligence, appears  to  exert  its  influence  by  and  through  the  gray 
substance  of  the  hemispheres,  and  may  be  allied  to  the  process 
styled  "  unconscious  cerebration  ;"  while,  on  the  other  hand,  actions 
which  are  perfectly  free,  deliberate,  and  responsible  are  conceived, 
scrutinized,  determined  upon,  and  recorded,  in  the  ganglionic  cells 
of  the  gray  matter  of  the  hemispheres,  before  the  will-force,  which 
is  determinative  and  free,  issues  its  mandate,  through  appropriate 
and  correlated  regions  of  the  motor  zone,  to  the  subservient  volun- 
tary muscles. 

Thought,  however,  does  not  necessarily  lead  to  expression  or 
the  induction  of  psycho-motor  action  in  all  cases.  As  M.  Allen 
Starr  appropriately  observes,  "  Expression  may  be  restrained  ;  the 
impulse  may  be  arrested.  This  restraint  of  the  flow  of  thought 
outward  in  expression  has  been  termed  inhibition  ;  and  inhibition, 
or  the  act  of  control,  is  the  highest  of  all  cortical  functions.  .  .  . 

"  In  this  summary  of  cortical  action,  it  will  be  noticed  that  no 
mention  has  been  made  of  the  higher  mental  acts, — of  judgment, 
reason,  imagination,  or  of  those  qualities  which  determine  talent 
and  character.  These  cannot,  as  yet,  be  assigned  to  any  particular 
region  of  the  cortex,  and  no  physical  basis,  no  mechanism  for  such 

19 


290  DISEASES   OF   THE   ^'ERVOUS   SYSTEM. 

purely  mental  acts,  can  as  yet  be  pictured  to  the  mind.  As  Hugh- 
lings  Jackson  has  well  said,  '  Psychical  states  are  not  functions  of 
any  centre,  but  are  simply  concomitant  with  functioning  of  the 
most  complex  nervous  arrangements.'  It  is  certainly  true  that  all 
mental  activity  has  a  physical  basis  in  the  brain ;  but  there  are 
numerous  problems  regarding  the  mutual  relation  of  thought  and 
cerebral  action  upon  which  physiology  has  thrown  no  light." 

In  evidence  of  the  important  fact  that  "  the  disturbance  of  the 
reason  which  follows  a  convulsive  fit,  and  especially  an  attack  of 
vertigo,  is  not  always  recognized  so  easily  as  it  might  be  supposed," 
Trousseau  cites  the  fact  that "  a  medical  man,  for  instance,  is  sent 
for  to  see  an  epileptic  immediately  after  an  attack.  The  patient 
answers  questions  pretty  well  to  the  point,  follows  out  the  doctor's 
prescriptions,  and  describes  his  feelings  pretty  accurately ;  but  a 
few  hours  later  has  not  only  forgotten  what  occurred  during  the 
attack,  as  the  rule  is,  but  he  has  forgotten  all  the  above  circum- 
stances, in  which  he  had  apparently  concurred  with  so  much 
presence  of  mind.  It  must,  therefore,  be  concluded  that  his  in- 
tellect had  been  deeply  perturbed."  "  Not  only,"  says  the  same 
author,  "  may  the  patient's  reason  remain  in  a  perturbed  condition 
for  some  time  after  the  attack,  although  a  superficial  observer  may 
not  perceive  it,  but  it  sometimes  happens  that  during  the  attack  the 
epileptic  seems  to  retain  enough  reason  to  appear  free''  How 
difficult,  therefore,  must  it  be  to  fathom  the  criminality  of  epi- 
leptics, if  authority  like  Trousseau's,  endorsed  as  it  is  by  that 
of  many  distinguished  psychologists,  teaches  us  that  inferences 
deducible  from  the  uncontrollable  impulses  of  epileptics  demand 
such  searching  and  careful  study  and  watchful  circumspection 
on  the  part  of  medical  experts !  Speaking  of  a  patient,  a  magis- 
trate and  a  very  intelligent  gentleman,  subject  to  epileptic  vertigo. 
Trousseau  states,  "He  belonged  to  a  literary  society  which  held 
its  meetings  at  the  Hotel-de-Ville  de  Paris.  At  one  of  these, 
during  a  discussion  on  an  important  historical  point,  he  is  seized 
with  (epileptic)  vertigo.  He  runs  quickly  down  to  the  Place  de 
I'Hotel-de-Yille,  and  walks  about  for  a  few  minutes  on  the  quays, 
avoiding  with  success  both  carriages  and  the  passers-by.  On 
recovering  himself  he  perceives  that  he  has  come  out  without  his 
great-coat  and  his  hat,  returns  to  the  meeting,  and  resumes  with  a 
perfectly  lucid  mind  the  historical  discussion  in  which  he  had 


EPILEPTIC  INSANITY  AND  ITS  MEDICO-LEGAL  RELATIONS.     291 

already  taken  a  very  active  part.  He  retained  no  recollection 
whatever  of  what  occurred  between  the  beginning  of  the  attack 
and  the  moment  he  recovered  himself.  Now,  had  this  patient 
quarrelled  with  and  killed  a  man  in  the  street,  would  a  magistrate 
have  believed  that  an  individual  who  five  minutes  before  and  five 
minutes  after  was  remarkably  intelligent,  and  who  during  this 
pretended  nervous  seizure  seemed  to  have  his  free  will,  could 
commit  murder  under  the  influence  of  an  irresistible  impulse? 
Sudden  and  irresistible  impulses  are  of  usual  occurrence  after  an 
attack  of  petit  mat,  and  pretty  frequent  after  a  regular  convulsive 
fit.  Patients  should  not  be  held  responsible  for  their  acts,  whether 
these  be  followed  or  not  by  grave  and  painful  consequences,  the 
gravity,  of  the  act  itself  having  nothing  to  do  with  the  question. 
The  individual  is  not  a  free  agent  for  the  time,  and  is,  therefore, 
free  from  guilt." 

The  sudden  outbursts  of  epileptic  fury  are  so  fearful  and  some- 
times so  disastrous  that  no  maniac  evinces  greater  or  more  un- 
controllable passion.  An  individual  so  affected  is  to  be  dreaded 
by  all  around  him,  and  may  even  become  his  own  enemy.  His 
violence  is  "  blind  and  instinctive."  The  most  terrible  and  motive- 
less crimes  are  perpetrated  by  epileptics  during  such  an  access  of 
dangerous  delirium,  which  may  last  from  a  few  hours  to  twelve  or 
fifteen  days.  It  must  be  borne  in  mind  that  these  fits  of  tem- 
porary insanity  may  sometimes  be  quite  independent  of  epileptic 
seizures  proper  ("  psychical  equivalents").  Victims  of  the  epilep- 
tic influence  are  apt  to  be  irritated  by  everything  about  them,  are 
inclined  to  wander  in  the  streets,  and  to  manifest  a  tendency  to 
obey  some  concealed,  quasi-mysterious  influence,  which  irresistibly 
impels  them  to  acts  of  violence.  They  are  intensely  unhappy, 
consider  themselves  persecuted  victims,  and,  as  in  other  forms  of 
insanity,  conceive  a  peculiar  aversion  to  their  friends  and  relatives, 
by  whom  they  believe  themselves  especially  persecuted.  "  If  they 
have  previously  harbored  any  feelings  of  hatred  or  thoughts  of 
revenge  against  any  one,  these  feelings  are  quickened  by  their 
complaint,  and  suddenly  roused  to  a  pitch  of  intensity  which 
prompts  them  to  immediate  action." 

Epileptic  insanity  is  essentially  impulsive  and  instinctive.  It 
is  well  known  that  epilepsy  soon  brings  out  in  bold  relief  the 
animal  traits  of  character,  whose  development  seems  to  keep  pace 


292  DISEASES   OF  THE  NEEVOUS   SYSTEM. 

with  a  slow  but  generally  certain  impairment  of  the  intellectual 
faculties.  Trousseau  says,  "  The  circumstance  that  repeated  blows 
are  struck  and  several  wounds  inflicted,  or  several  pei'sons  injured, 
deserves  to  be  specially  noticed,  and  seems  to  characterize  the 
condition  of  furor  epileptieus.  Hence  it  may  be  of  considerable 
importance  in  a  medico-legal  point  of  view."  I  would  particu- 
larly invite  attention  to  the  fact  that  after  epilepsy  has  long  sub- 
sided and  is  apparently  cured  it  often  breaks  out  in  all  its  pristine 
intensity,  a  statement  which  is  also  true  of  the  delirious  form  of 
the  disease. 

Hammond,  in  commenting  upon  the  possibilities  of  "  irregular 
or  abortive  paroxysms'^  of  epilepsy,  cites  a  very  interesting  and  re- 
markable case  which  occurred  in  his  practice  during  the  autumn  of 
1875.  "  The  patient,  who  was  engaged  in  active  business  as  a  manu- 
facturer, left  his  office  at  about  nine  A.M.,  saying  he  was  going  to  a 
florist's  to  purchase  some  bulbs.  He  remained  absent  eight  days. 
He  was  tracked  all  over  the  city,  but  the  detectives  and  friends 
were  always  an  hour  or  more  behind  him.  It  was  ascertained  that 
he  had  been  to  theatres,  to  hotels,  where  he  slept,  to  shops  where 
he  had  made  purchases,  and  that  he  had  made  a  journey  of  a 
hundred  miles  from  New  York,  and,  losing  his  ticket  and  not 
being  able  to  give  a  satisfactory  account  of  himself,  was  put  off 
the  train  at  a  way-station.  He  had  then  returned  to  New  York, 
passed  the  night  at  a  hotel,  and  on  the  eighth  day,  at  about  ten 
o'clock,  made  his  appearance  at  his  office.  He  had  no  recollection 
of  any  one  event  which  had  taken  place  after  leaving  his  place  of 
business,  eight  days  previously,  till  he  awoke  on  the  morning  after 
his  return  to  the  city,  and  found  himself  in  a  hotel  at  which  he 
was  a  stranger.  It  was  ascertained  beyond  question  that  in  all 
this  time  his  actions  had  been  entirely  correct  to  all  appearance, 
that  his  speech  was  coherent,  and  that  he  had  acted  entirely  in 
all  respects  as  any  man  in  the  full  possession  of  his  mental  facul- 
ties would  have  acted.  He  had  drunk  nothing  but  a  glass  of 
ale,  which  he  took  with  some  oysters  at  a  restaurant  in  Sixth 
Avenue.'^ 

This  case  is  of  vital  importance  in  the  medico-legal  literature 
of  epilepsy ;  its  points  are  so  salient  that  comment  is  unnecessary. 

Eighteen  years  ago  a  case  very  similar  to  Dr.  Hammond's  fell 
under  my  care,  in  the  person  of  a  young  lady  from  Louisiana, 


EPILEPTIC  INSANITY  AND  ITS  MEDICO-LEGAL  RELATIONS.     293 

affected  with  convulsive  epilepsy.  During  the  post-epileptic  stage 
her  actions  were  purely  automatic  for  eight  or  ten  days.  She 
would  execute  the  finest  needle-work,  read  books  and  newspapers, 
or  even  converse  with  visitors,  and  yet  remain  utterly  unconscious 
of  all  details  pertaining  to  such  actions.  Suddenly  returning  to 
her  normal  condition,  she  recollected  nothing  that  had  taken 
place  during  the  above-named  period. 

Hammond  asserts  that  "  Most,  if  not  all,  of  the  cases  of '  double 
consciousness'  that  have  been  reported  are  doubtless  epileptic  in 
character.  An  interesting  case  of  the  kind  has  been  related  by 
Azam.  It  is  that  of  a  young  woman  who,  after  having  suffered 
from  hysteria  and  convulsions,  had  two  distinct  phases  of  exist- 
ence, living,  in  fact,  two  separate  and  different  lives,  and  exhibiting 
different  likes  and  dislikes  and  mental  characteristics."  * 

Ray,  in  speaking  of  epilepsy  and  its  legal  consequences,  in  his 
"  Medical  Jurisprudence  of  Insanity,"  observes,  "  Another  direct 
though  temporary  effect  of  the  epileptic  fit  is  to  leave  the  mind  in 
a  morbidly  irritable  condition,  in  which  the  slightest  provocation 
will  derange  it  entirely.  Sometimes  this  irritability  is  accompanied 
by  a  sense  of  anxiety,  distrust,  jealousy,  and  unfounded  fear,  and 
sometimes  by  great  activity  of  the  lower  propensities.  .  .  .  Epi- 
lepsy seldom  continues  for  any  length  of  time  without  destroying 
the  natural  soundness  of  the  intellect,  rendering  the  patient  listless, 
fretful,  indisposed,  and  unable  to  think  for  himself,  yielding,  Avith- 
out  any  will  of  his  own,  to  every  outward  influence,  and  finally 
sinking  into  hopeless  fatuity  or  becoming  incurably  maniacal." 

Again,  from  a  medico-legal  point  of  view,  we  find  the  following 
pertinent  remarks  of  the  same  author  :  "  To  determine  exactly 
the  mental  condition  of  an  epileptic  at  the  moment  of  his  com- 
mitting a  criminal  act  is  oftentimes  a  difficult  task.  It  may  have 
taken  place  in  the  absence  of  any  observer,  in  a  fit  of  fury  that 
rapidly  passed  away,  and  which,  perhaps,  may  not  have  followed 
any  previous  paroxysm ;  or  the  accused,  though  subject  to  the 
disease,  may  not  have  recently  suffered  an  attach,  and  may  have 
appeared  perfectly  rational  to  those  around  him.  .  .  .  Cases  of 
this  kind  should  be  closely  scrutinized,  and  where  the  accused  has 
been  undeniably  subject  to  epilepsy,  he  should  have  the  benefit  of  every 

*  Hammond,  Diseases  of  the  Nervous  System. 


294  DISEASES   OF    THE    NEEVOUS   SYSTEM. 

reasonable  doubt  that  may  arise  resjyecting  his  sanity.  Less  than 
this  common  humanity  could  not  ask  ;  more,  even,  has  sometimes 
been  granted  under  the  operation  of  milder  codes  than  the  English 
common  law." 

A  great  difficulty  in  the  way  of  the  scientific  alienist  is  the 
prejudiced  misconception,  so  commonly  entertained,  that  no  single 
faculty  of  the  mind  can  become  incapable  of  exercising  its  appro- 
priate function  without  a  necessary  involvement  of  every  other 
faculty.  Yet  the  reverse  of  this  proposition  is  probably  true. 
The  perceptive,  emotional,  and  intellectual  faculties  may  retain  an 
apparent  integrity,  or  even  exhibit  an  unusual  degree  of  vigor, 
while  the  volitional  centres  may  be  much  at  fault.  On  the  other 
hand,  the  will  may  be  normal,  while  one  or  all  of  the  above  fac- 
ulties may  be  enfeebled.  Indeed,  I  imagine  that  any  one  of 
these  faculties,  though  they  are  so  intimately  correlated,  may  be 
exercised  independently  of  the  others. 

Hammond  furnishes  the  following  forcible  elucidation  of  the 
point  under  consideration  :  "  (1)  The  brain  may  be  so  disordered 
that  insanity  is  manifested  only  as  regards  the  will.  There  are 
no  false  conceptions  of  the  intellect,  and  no  emotional  disturbance, 
but  solely  an  inability  to  exert  the  full  will-power  either  affirma- 
tively or  negatively.  (2)  Many  instances  of  '  morbid  impulse' 
are  uncomplicated  cases  of  volitional  insanity,  in  which  an  idea, 
suddenly  flashing  across  the  mind,  is  immediately  carried  out  by 
the  individual,  although  his  intellect  and  his  emotions  are  strongly 
exerted  against  it.  Thus,  a  person  who  previously  has  not  ex- 
hibited any  very  obvious  symptoms  of  mental  derangement — 
though  careful  inquiry  will  invariably  show  that  slight  evidences 
of  cerebral  disease  have  been  present  for  some  days — instan- 
taneously feels  a  morbid  impulse  to  commit  a  murder  or  perpetrate 
some  other  criminal  act." 

How  careful,  therefore,  should  we  be  in  our  deductions  as  to  the 
responsibility  of  epileptic  criminals  !  Their  disease  is  a  constant 
source  of  irritation  to  a  nervous  system  long  since  exhausted  by 
continuous  shocks,  or  ''  cortical  explosions ;"  hence  a  conspicuous 
morbid  irritability, — "  irritable  weakness."  The  nervous  system, 
lilvc  a  Leyden  jar,  goes  on  accumulating  its  dangerous  forces,  to 
be  finally  expended  in  explosions  of  long-pent-up  and  concentrated 
violence. 


EPILEPTIC  INSANITY  AND   ITS  MEDICO-LEGAL  RELATIONS.     295 

I  acknowledge  that  we  are  ignorant  of  the  true  pathology  of 
epilepsy,  and  admit  that  this  disease  at  times  exhibits  obscure  and 
contradictory  features  difficult  to  explain,  and  which  do  not  exactly 
correspond  with  the  ordinary  manifestations  of  epilepsy  as  gen- 
erally described ;  but  does  it  not  seem  presumptuous  to  maintain 
that  criminality  is  therefore  present,  and  that  the  prisoner  at  the 
bar  should  not  have  the  benefit  of  the  doubt  ?  Does  not  the 
physician  in  his  daily  routine  find  cases  of  fever  or  of  inflam- 
mation apparently  similar,  but  varying  so  decidedly  in  type  and 
in  their  special  manifestations  as  often  to  test  his  diagnostic  skill 
to  the  utmost  ?  Do  the  maladies  that  we  are  constantly  called 
upon  to  treat  correspond  faithfully  with  the  typical  and  classical 
descriptions  of  the  text-books  ?  Can  the  study  of  any  single  case 
of  a  given  disease  thoroughly  enlighten  us  as  to  the  symptoma- 
tology and  prognosis,  or  demonstrate  to  us  the  most  efficacious 
treatment  of  the  disease  in  its  varying  forms  ?  If  our  experience 
as  practitioners  of  medicine  proves  to  us  the  folly  of  such  a  hope, 
should  an  unfortunate  epileptic  forfeit  his  life  because  the  symp- 
toms of  his  disease  do  not  precisely  correspond  with  "  hypothetical 
cases"  with  which  over-zealous  prosecuting  attorneys  have  bur- 
dened their  memories  after  a  night's  cramming  from  standard 
authorities  ?  Are  the  intricacies  of  mental  disease  susceptible  of 
perfect  elucidation  by  legal  acumen  ?  Must  an  unhappy  epileptic 
receive  a  felon's  doom  under  the  weight  of  assertions  declaimed 
before  a  jury,  mostly  untenable  and  unscientific? 

Before  proceeding  further  it  may  be  well  to  consider  the  true 
meaning  of  the  term  "  responsibility/'  which  occurs  so  often  with 
us.  Dr.  BuckniU's  conclusions  express  my  own  ideas  upon  the 
subject,  and  are  as  follows  :  "  Responsibility  depends  upon  power, 
not  upon  knowledge,  still  less  upon  feeling.  A  man  is  responsible 
to  do  that  which  he  can  do,  not  that  which  he  feels  or  knows  it 
right  to  do.  Tf  a  man  is  reduced  under  thraldom  to  passion  by 
disease  of  the  brain,  he  loses  moral  freedom  and  responsibility, 
although  his  knowledge  of  right  and  wrong  may  remain  intact." 

It  appears,  therefore,  that  an  extreme  difficulty  exists  in  deter- 
mining the  criminal  responsibility  of  epileptics,  and  that  their 
mental  condition  is  entitled  to  the  most  careful  study,  and  should 
be  regarded  with  the  most  elaborate  circumspection  by  medical 
jurists. 


296  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Facts  cited  by  such  eminent  men  in  science  as  Baillarger, 
Boileau  de  Castelnau,  Delasiauve,  Echeverria,  Gray,  Esquirol, 
Falret^  Legrand  du  SauUe,  Ray,  Schroeder  van  der  Kolk,  Mauds- 
ley,  and  Spitzka  go  to  support  the  same  opinion. 

The  hallucination  is  generally  forgotten  after  the  seizure  has 
passed  away,  but  the  manner,  attitude,  gestures,  and  acts  are 
evidently  referable  to  the  fear  or  horror  engendered  by  some 
imaginary  danger, — imaginary,  yet  to  its  subject  a  fearful  reality. 

Epileptic  delusions  are  often  of  a  strong  religious  character ; 
and  these  at  first  sight  apparently  harmless  ideas  may  be  the 
source  of  most  sanguinary  actions.  They  are  usually  of  a  homi- 
cidal character,  although  self-mutilation  or  suicide  may  be  the 
form  of  culmination. 

It  is  well  known  that  epilepsy  soon  brings  into  bold  relief  the 
animal  traits  of  character,  whose  development  seems  to  keep  pace 
with  the  slow  but  generally  certain  impairment  of  the  intellectual 
faculties.  Epileptics  are  commonly  inveterate  masturbators,  and 
the  crime  of  rape  or  sodomy  may  often  be  traced  to  the  salacious 
tendencies  developed  under  the  brutalizing  effects  of  the  disease. 
Of  course,  where  epilepsy  of  the  masked  form  is  pleaded  in  ex- 
tenuation of  crime  of  this  sort,  you  should  closely  investigate 
the  history  of  the  accused  for  some  evidence  of  epilepsy  in  some 
other  form;  examine  him  carefully  for  vices  of  conformation, 
which  quite  commonly  accompany  this  formidable  affection;  test 
his  memory,  not  only  in  a  general  way,  but  also  particularly  in 
reference  to  the  acts  which  have  brought  him  under  the  eye  of  the 
law. 

An  essential  characteristic  of  criminal  acts  perpetrated  by  epi- 
leptics while  under  the  influence  of  the  special  morbid  psychical 
condition  is  their  instantaneousness,  their  abruptness  and  sud- 
denness. In  two  cases  reported  by  Dr.  Auzouy,  where  larvated 
(mental  or  cerebral)  epilepsy  was  pleaded  in  extenuation  of  the 
crime  of  sodomy,  that  learned  physician  was  enabled  to  determine 
the  fact  that  epilepsy  was  not  present  by  ascertaining  the  absence 
of  these  evidences  of  the  disease,  together  with  a  perfect  recollec- 
tion on  the  part  of  the  prisoners  of  all  the  incidents  connected 
with  the  perpetration  of  the  crime. 

There  is  ample  authority  for  the  statement  that  total  abolition 
of  consciousness  in  these  cases,  although  usual,  is  not  at  all  neces- 


EPILEPTIC  INSANITY  AND  ITS  MEDICO-LEGAL  RELATIONS.     297 

sary,  and  that  a  state  bearing  some  resemblance  to  somnambulism 
may  exist.  Dr.  M.  G.  Echeverria  has  clearly  elucidated  this  sub- 
ject in  an  article  of  very  high  value  in  the  American  Journal  of 
Insanity  for  January,  1873.  He  shows  by  citations  from  the 
works  of  Delasiauve,  Legrand  du  Saulle,  Boileau  de  Castelnau, 
and  Trousseau,  and  from  cases  in  his  own  practice,  which  has 
been  remarkably  rich  in  epilepsy,  that  premeditation  and  action 
upon  such  motives  as  revenge,  jealousy,  etc.,  are  by  no  means 
uncommon  in  epilepsy. 

Recognizing,  therefore,  a  frame  of  mind  to  which  epileptics  are 
obnoxious,  which  is  strange,  indescribable,  and  sui  generis,  the 
result  of  a  morbid  condition  over  which  they  have  no  control,  and 
for  which,  therefore,  they  are  not  responsible,  how  can  we  attempt 
to  designate  with  precision  the  dubious  coufines  where  respon- 
sibility ends  and  criminality  begins  ? 

In  relation  to  masked  epilepsy,  Maudsley,  in  his  "  Physiology 
and  Pathology  of  the  Mind,"  makes  these  observations : 

"  In  such  cases  there  are  often  sudden  and  vivid  temporary 
hallucinations.  Again,  the  mental  disorder  which  sometimes  takes 
the  place  of  an  epileptic  attack,  representing,  in  fact,  a  mashed 
epilepsy,  may  appear  as  simple  impulsive  insanity.  ...  It  hap- 
pens sometimes  that  the  patient  succeeds  in  controlling  the  morbid 
idea  for  a  time,  calls  up  other  ideas  to  counteract  it,  warns  his 
probable  victim  to  get  out  of  his  way,  or  begs  earnestly  to  be  him- 
self put  under  some  restraint ;  but  at  last,  perhaps  from  a  further 
deterioration  of  nervous  element  through  bodily  disturbance,  the 
morbid  idea  acquires  a  fatal  predominance ;  the  tension  of  it 
becomes  excessive ;  it  is  no  longer  an  idea,  the  relations  of  which 
the  mind  can  contemplate,  but  a  violent  impulse,  into  which  the 
mind  is  absorbed,  and  which  irresistibly  utters  itself  into  action." 

That  the  presumption  of  moral  irresponsibility  is  in  favor  of 
the  epileptic  accused  of  crime  may  be  fairly  concluded  from  the 
weight  of  authority,  from  the  facts  I  have  given,  and  from  a 
humane  application  of  the  rule  that  the  accused  is  entitled  to  the 
benefit  of  any  reasonable  doubt  of  his  responsibility  and  culpa- 
bility. 

The  following  remarkable  passage  by  Ray  (Trial  of  Winnemore, 
American  Journal  of  Insanity,  October,  1867)  shows  that  this 
venerable  IN'estor  of  American  psychology  arrived  at  the  same 


298  DISEASES   OF   THE   NERVOUS   SYSTEM. 

conclusion  nearly  a  quarter  of  a  century  ago :  "  In  view  of  what 
we  already  know  of  epilepsy,  and  what  still  remains  to  be  learned, 
we  have  a  right  to  require  the  utmost  circumspection,  and  the 
closest  investigation,  whenever  the  legal  liabilities  of  epileptics 
are  in  question.  The  fact  of  its  existence  being  established,  is  it 
going  too  far  to  say  that  legal  responsibility  is  presumptively  an- 
nulled, and  that  the  burden  of  proof  lies  on  the  party  that  alleges 
the  contrary  ?  People  are  scarcely  ready  for  it  yet,  perhaps,  but 
to  that  complexion  will  they  come  at  last." 

In  cases,  also,  in  which  heredity  and  the  neuropathic  temper- 
ament exist  in  combination  with  a  history  of  cranial  injury,  or 
where  symptomatic  manifest5,tions  of  focal  lesions  of  the  motor 
tract  are  indicated  by  "  the  signal  symptom'^  of  "JacJcsonian  epi- 
lepsy" the  presumption  of  doubt  in  criminal  cases  must  always 
be  in  favor  of  the  defendant. 

In  this  connection  Forbes  Winslow  makes  the  following  obser- 
vations :  "  Do  we  estimate  in  a  manner  commensurate  with  its 
grave  and  vital  importance  the  necessity  of  watching,  with  the 
most  scrupulous  care,  the  cerebral  symptoms  that  follow  all  me- 
chanical injuries  to  the  head  ?  I  am  satisfied  that  a  vast  amount 
of  organic,  chronic,  and  incurable  disease  of  the  brain  and  disorder 
of  the  mind  can  be  directly  traced  to  this  cause.  In  many  cases 
positive  and  undoubted  evidences  of  disease  of  the  brain  are  pres- 
ent without  exciting  a  suspicion  as  to  the  cerebral  origin  of  this 
affection,  or  character  of  the  symptoms.  A  maji  receives  a  blow 
upon  the  liead.  He  may  suffer  from  partial  concussion  of  the 
brain,  or  be  merely  stunned.  He  recovers  without  any  apparent 
inconvenience  from  the  injury,  but  subsequently  head-symptoms 
exhibit  themselves,  clearly  the  consequence  of  the  injury  which 
the  brain  had  sustained  many  years  previously.  I  am  satisfied 
that  the  importance  of  this  subject  cannot  be  exaggerated.  Re- 
peatedly have  I  had  cases  of  epilepsy  bidding  defiance  to  all  treat- 
ment, tumors,  abscesses,  cancer,  softening  of  the  brain,  as  well  as 
insanity  in  its  most  formidable  types,  under  my  care,  whose  origin 
could  unquestionably  be  traced  back,  for  periods  varying  from 
eight  to  ten,  fifteen,  and  even  twenty  years,  to  damage  done  to 
the  delicate  structure  of  the  brain  by  injuries  inflicted  upon  the 
head !" 

Confirmatory  of  Forbes  Winslow's  views,  Griesinger  ("  Mental 


EPILEPTIC  INSANITY  AND   ITS   MEDICO-LEGAL   RELATIONS.     299 

Pathology  and  Therapeutics")  makes  the  following  observations  : 
"  It  frequently  happens  that  on  minute  inquiry  the  physician 
learns  from  the  relatives  of  the  patient  of  former  circumstances  of 
this  kind  which  had  been  almost  forgotten, — a  severe  kick  from  a 
horse,  a  fall  or  blow  on  the  head  which  was  followed  by  insensi- 
bility. Sometimes  the  friend  now  remembers,  for  the  first  time, 
that  since  the  accident  a  certain  change  had  taken  place  in  the 
character  of  the  patient, — that  he  had  become  fretful,  irritable, 
perverse,  etc.  This  change,  however,  had  been  little  heeded,  and 
had  not  even  been  recognized  in  its  true  significance  as  a  precursor 
of  insanity  when  the  disease  broke  out." 

The  following  details  of  a  recent  case  in  my  practice  confirm 
these  views.  I  have  treated  for  the  last  three  years  a  case  of  con- 
vulsive epilepsy,  in  one  of  the  most  intelligent  merchants  of  this 
city.  After  an  exhaustive  analysis  of  the  history  of  the  case  and 
most  careful  study  of  its  etiology,  my  diagnosis  was  idiopathic 
epilepsy.  This  summer,  while  conversing  with  the  patient,  my 
attention  was  attracted  to  an  ugly  scar  upon  the  scalp,  in  close 
relationship  with  the  upper  portion  of  the  left  ascending  frontal 
convolution  :  its  presence  was  revealed  because  the  patient  had 
had  his  hair  very  closely  clipped  on  account  of  the  extreme  heat 
which  then  prevailed.  I  was  much  surprised  at  finding  it,  and 
inquired  as  to  its  cause :  the  patient  replied  that  he  had  received 
a  severe  kick  from  a  horse  in  that  region  when  a  boy,  which  had 
rendered  him  unconscious  for  several  days,  but  that  he  had  not 
thought  the  fact  worth  mentioning.  Thus  a  serious  omission  had 
occurred  in  his  recital,  notwithstanding  all  my  care,  for  it  is  my  cus- 
tom to  investigate  with  the  utmost  detail  the  possibility  of  trauma- 
tism in  all  cases  of  disease  of  the  nervous  system,  and  especially  in 
epilepsy  and  insanity.  With  intent,  therefore,  to  avail  himself 
of  the  resources  of  cranial  surgery,  in  all  appropriate  cases  of 
epilepsy  and  insanity  at  least,  the  physician  should  cause  the  scalp 
to  be  shaven,  whether  the  patient  admits  any  traumatic  history  or 
not.  Previous  injuries  to  the  head,  moreover,  are  frequently  kept 
from  the  knowledge  of  young  people  by  their  parents,  especially 
when  nervous  or  mental  symptoms  supervene,  so  that  in  later  years 
the  patient  may  have  no  recollection  of  an  injury,  and  thus  be 
unable  to  furnish  a  most  important  hint  to  his  medical  examiner. 

Regarding  temporary  hallucinations,  to  which  epileptics  are  so 


300  DISEASES   OF   THE   NERVOUS   SYSTEM. 

subject,  Hammond  observes,  "  We  all  at  times  momentarily  have 
hallucinations  and  delusions,  but  the  judgment  at  once  prevents 
continued  deception.  When  this  fails  to  be  the  case,  delusions 
exist,  and  we  are  the  subjects  of  intellectual  insanity." 

Maudsley  observes,  "Sometimes  an  attack  of  mania  notably 
precedes  an  epileptic  fit,  or  a  series  of  epileptic  fits  ;  but  it  is  not 
so  clearly  understood  that  the  mental  derangement  so  occurring 
may  have  the  form  of  profound  moral  disturbance,  with  homicidal 
propensity,  but  without  manifest  intellectual  disturbance." 

Another  fact  to  be  continually  borne  in  mind  by  medical  experts 
is  the  possibility  of  the  existence  of  "  epileptic  vertigo'^  in  the  entire 
absence  of  convulsive  attacks  or  any  other  epileptic  complications. 
In  this  connection  the  affirmation  of  Schroeder  van  der  Kolk 
should  be  always  remembered,  that  epileptic  vertigo  "  depresses 
the  mental  j)Owers  much  more  rapidly  than  spasms  without  loss 
of  consciousness  ;"  by  this  latter  expression  apparently  intending 
to  designate  "  Jacksonian  epilepsy,"  which  had  not  been  strictly 
diiferentiated  in  his  day. 

It  may  be  argued  that  the  extenuation  in  these  cases  is  far- 
fetched, and  that  the  ingenuity  of  doctors  and  the  evasive  skill  of 
la^vyers  are  prejudicial  to  the  interests  of  the  community,  whose 
sense  of  justice  is  daily  outraged  by  the  ever-ready  j)lea  of  insanity. 
Such  a  conclusion  is  unfair  and  fallacious,  and  deserves  but  little 
consideration.  Science  is  truth  :  because  an  abuse  exists  we  are 
not  called  upon  to  abate  our  scientific  zeal  in  cases  which,  though 
obscure  and  marvellous,  are  yet  within  the  scope  of  scientific 
analysis.  "  If  any  one  supposes  that  the  marvellous  is  incom- 
patible with  true  science,  deserving  only  rebuke  and  derision,  let 
him  consider  that  every  step  in  the  progress  of  science  has  been 
but  the  repetition  of  a  marvel,  scouted  at  first  as  unworthy  the 
serious  attention  of  the  philosopher,  and  welcomed  at  last  with 
triumphant  admiration  and  joy." 

I  would,  moreover,  repeat  that  in  cases  of  alleged  epilepsy  the 
apjparent  absence  of  epileptic  convulsions  for  years  is  no  proof 
of  the  cure  of  the  disease.  The  morbid  basis  may  still  exist  as 
"  masked  epilepsy,"  epileptic  vertigo,  or  nocturnal  epilepsy,  and 
these  forms  may  linger,  bidding  defiance  to  ordinary  investigation 
unless  conducted  by  those  who  are  on  the  watch  for  the  many 
subtle  forms  of  this  extraordinary  disease. 


EPILEPTIC  INSANITY  AND  ITS  MEDICO-I.EGAL  EELATIONS.     301 

EpileptiG  dementia  may  terminate  in  stupor,  imbecility,  or  idiocy 
(Esquirol),  which,  as  Spitzka  observes,  "is  intimately  dependent 
on  the  frequency  of  the  convulsive  attacks,  .  .  .  according  as 
these  attacks  begin  later  or  earlier  in  life.  Aside  also  from 
those  attacks  of  furious  madness  or  purposeless  automatism  re- 
placing the  convulsive  attack,  and  which  may  be  regarded  as 
psychical  equivalents  of  the  convulsion,  there  are  forms  of  more 
or  less  protracted  insanity  which  follow  some  individual  epileptic 
attack,  or  break  out  in  the  interval,  or  finally  extend  over  the 
entire  interval,  which  are  to  be  strictly  distinguished  from  these 
forms." 

Spitzka  quotes  Samt  as  including  both  the  "petit  mat  and 
grand  mal  intellectueU'  of  Falret  under  the  head  of  acute  post- 
epileptic insanity,  and  defines  the  latter  as  insanity  immediately 
following  the  convulsive  paroxysm,  and  pursuing  an  acute  course. 
He  subdivides  this  acute  form  into — 

1st.  Simple  post-epileptic  stupor,  which  may  be  complicated  with 
dreamy  delirium,  etc. 

2d.  Post-epileptic  morbid  conditions  of  fear  or  fright,  either 
simple  or  complicated  with  delire  raisonnant  or  great  excitement. 

3d.  Post-epileptic  maniacal  moria.  This  form  is  rare,  and 
simulates  ordinary  acute  mania  to  such  an  extent  that  even  the 
expert  may  be  deceived.  Spitzka  believes  the  treacherous  and 
malicious  character  of  the  violence  will  enable  us  to  distinguish 

o 

this  disorder  from  ordinary  attacks  of  acute  mania. 

Under  the  head  of  chronic  protracted  epileptic  insanity  Spitzka 
says  Samt  describes  many  cases  which  are  evidently  related  to  the 
post-epileptic  forms. 

Spitzka  adds,  "  Just  as  the  forms  characterized  in  Samt's  classi- 
fication were  designated  post-epileptic,  these  latter,  which  are  far 
from  infrequent,  deserve  to  be  designated  as  prodromal  or  pre- 
epileptic. If  the  chronological  relation  of  the  mental  disturbance 
be  made  a  principle  of  classification,  much  confusion  could  be 
avoided  by  adopting  the  following  order : 

"  1.  The  epileptic  psychical  equivalent,  which  replaces  the  con- 
vulsive attack. 

"  2.  The  acute  post-epileptic  insanity,  which  almost  immediately 
follows  the  convulsive  attack.  .  .  . 

"  3.   The  pre-epileptic  insanity,  which   precedes   the  outbreak 


302  DISEASES   OF   THE   NERVOUS  S^TEM. 

of  a  convulsive  attack  or  its  equivalent,  and  increases  up  to  the 
moment  when  the  paroxysm  explodes. 

"  4.  The  purely  intervallary  epileptie  insanity,  which,  neither 
immediately  following  nor  preceding  a  paroxysm,  occurs  in  the 
interval  between  such." 

Spitzka  finally  states  that  it  is  possible  for  all  these  forms  to 
occur  together,  and  in  addition  there  is  very  apt  to  be  a  background 
of  protracted  epileptic  dementia  to  complicate  the  picture. 

In  conclusion,  with  regard  to  the  disposal  of  cases  of  this  char- 
acter,— as  of  persons  acquitted  of  crime  on  the  ground  of  in- 
sanity, whether  of  epileptic  origin  or  not, — while  I  would  exten- 
uate their  faults  and  seek  to  measure  a  full  allowance  of  justice 
and  of  mercy  to  them,  I  would  not  forget  what  is  due  to  the  com- 
munity at  large.  The  homicidal  lunatic  should  not  be  turned 
loose  upon  an  outraged  community,  which  must  watch  over  its 
own  preservation  and  enforce  law,  which  alone  can  protect  life 
and  property  and  preserve  the  liberties  of  individuals.  On  the 
contrary,  when  an  epileptic  criminal's  life  has  been  saved  by  a 
plea  of  insanity,  the  sentence  should  be  confinement  in  an  insane 
asylum  for  life,  where  his  dangerous  and  destructive  propensities 
can  be  held  in  check  and  the  public  secured  from  alarm  and  injury. 
It  matters  not  that  he  may  be  sane  when  acquitted,  or  that  a 
sane  man  should  not  be  incarcerated  in  a  lunatic  asylum  :  "  aux 
grands  maux  les  grands  remedesJ"  No  person  who  has  been 
proved  liable  to  explosive  fits  of  homicidal  insanity  should  be 
allowed  his  liberty  during  an  apparent  convalescence  whose  con- 
tinuance no  expert,  however  great  his  attainments  or  experience, 
can  guarantee.  Nor,  on  the  other  hand,  is  it  just  or  humane  that 
after  acquittal  for  a  homicide  actually  committed,  such  an  epileptic 
should  be  submitted  to  the  risks  of  another  prosecution,  for  he 
might  repeat  the  act  and  be  sentenced  to  death  at  some  subsequent 
time. 


LECTURE  Xyill. 

GENEEAL   PARALYSIS   OF   THE   INSANE. 

History —  Etiology — Symptomatology  —  Diagnosis  —  Prognosis — Pathological 
Anatomy — Treatment — Cerebral  Surgery  in  General  Paralysis. 

Gentlemen, — This  formidable  malady  is  one  of  the  most 
destructive  both  to  mind  and  body  in  the  catalogue  of  diseases. 
I  have  never  known  a  patient  afflicted  with  it  to  be  in  the  slightest 
degree  benefited  by  treatment :  its  correct  diagnosis  is  really  his 
death-knell. 

Medical  literature  has  been  flooded  with  able  contributions  to 
the  study  of  this  disorder. 

Blaudford  justly  credits  French  physicians  with  having  first 
recognized  and  described  it  as  a  special  form  of  insanity ;  but 
"  the  credit,"  he  says,  "  must  be  divided  among  several."  Esqui- 
rol  was  undoubtedly  the  first  who  held  that  insanity  complicated 
with  paralysis  was  incurable,  but  he  did  not  perceive  that  the 
combination  of  these  two  elements  essentially  constituted  the  dis- 
ease, regarding  the  paralysis  as  a  complication  of  the  insanity. 

Bayle  in  1822  maintained  that  as  a  sequence  of  chronic  inflam- 
mation of  the  arachnoid  a  form  of  insanity  w^as  developed,  and 
that  "  the  mental  disturbance  and  paralysis  were  synchronous." 
Delay e  in  1824  wrote  that  the  disease  described  above  was  a 
softening  or  atrophy  of  the  brain,  and  was  not  always  accompanied 
by  insanity.  Blandford  further  states  that  Calmeil  in  1826  "  gave 
a  most  complete  account  of  it,  and  to  him  frequently  is  ascribed 
the  merit  of  having  been  the  discoverer."  In  1859  he  published 
a  treatise  on  the  subject,  in  which  he  set  forth  his  latest  views 
of  its  nature.  All  authors  who  have  contributed  to  the  literature 
of  insanity  since  then  have  devoted  much  time  and  labor  to  the 
investigation  of  this  subject. 

"  Of  the  many  divisions  of  general  paralysis  into  several  clinical 
types,  all  of  them  naturally  more  or  less  arbitrary,  I  know  no  other 

303 


304  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

SO  satisfactory  as  Meynert's  eight.  ('  Klinische  Vorlesungen  iiber 
Psychiatrie/  Wien,  1890,  Braumiiller.') 

"  1.  Simple  progressive  dementia,  with  the  usual  progressive 
motor  impairment  which  accompanies  it. 

"2.  With  delusions  of  grandeur  and  with  marked  motor  dis- 
turbances, which  appear  simultaneously  and  are  progressive. 
The  mental  state  is  usually  of  exaltation,  but  there  may  be 
depression. 

"  3.  Of  the  same  type  as  the  last,  but  lacking  its  steadily  pro- 
gressive character, — that  is,  with  remissions. 

"  4.  Cases  in  which  the  characteristic  exaltation  and  grand 
delusions  reach  such  an  astounding  height  that  manifest  motor 
symptoms  are  looked  for  with  confidence  from  day  to  day,  and 
yet  may  not  appear  even  for  a  year,  any  slight  incoordination 
naturally  being  obscured  by  the  general  muscular  disturbance. 
Meanwhile  there  may  be  such  an  improvement  as  to  simulate  a 
recovery. 

"  5.  A  very  rare  form,  with  alternate  symptoms  of  exaltation 
and  depression. 

"  6.  With  early  furious  delirium,  painful  hallucinations,  con- 
fusion and  incoherence  somewhat  resembling  acute  delirium. 

"  7.  In  which  the  characteristic  indications  appear  secondary  to 
other  forms  of  insanity, — for  instance,  after  paranoia  or  melan- 
cholia. 

"  8.  The  combined  form,  with  sclerosis  in  the  whole  cerebro- 
spinal tract,  the  symptoms  of  tabes  or  spastic  paralysis  pre- 
dominating according  as  the  posterior  or  lateral  columns  of  the 
spinal  cord  are  chiefly  involved.  The  ascending  type,  in  which 
the  cord  is  first  affected,  is  rare.  Optic  neuritis,  ending  in  atrophy 
and  paralysis,  especially  of  the  ocular  muscles,  may  precede  marked 
mental  symptoms."  * 

Folsom,  in  his  excellent  monograph  on  "  The  Early  Stage 
of  General  Paralysis,"  observes  that  "  the  impression  of  general 
paralysis,  however,  almost  universal  among  officers  of  insane 
asylums  and  the  medical  profession,  is  of  a  disease  in  which  the 
symptoms  are  early  difficulty  of  speech,  muscular  tremor,  and 
uncertain  gait,  accompanied  by  remarkable  mental  weakness,  and 

*  Folsom,  Some  Points  regarding  General  Paralysis,  May,  1891. 


GENERAL   PARALYSIS   OF   THE   INSANE.  305 

in  many  eases  manie  des  grandeurs.''  The  only  general  medical 
text-books  describing  the  obscure  insidious  stage  are  the  second 
edition  of  Striimpell  and  Pepper's  System  of  Medicine;  and, 
except  Meynert,  the  writers  who  have  recognized  it,  so  far  as  their 
opinions  are  given,  agree  with  Voisin  as  to  the  impossibility  of 
diagnosticating  general  paralysis  in  this  ea7'ly  *  stage. 

"  Indeed,  the  early  period  of  this  disease,  as  generally  described, 
is  a  comparatively  late  stage,  and,  excepting  a  few  writers,  this 
statement  holds  good  at  least  until  a  few  years  ago.  With  regard 
to  the  occasional  articles  in  medical  journals  which  have  appeared 
from  time  to  time,  within  the  last  forty  years,  on  the  prodromal 
symptoms  of  general  paralysis,  reference  has  for  the  most  part 
been  made  to  particular  acts  rather  than  to  a  general  mental  state." 

"In  this  country,  Spitzka,  in  his  treatise  on  insanity,  in  1883, 
defines  the  initial  stage  of  general  paralysis  as  so  insidious  in  its 
development  of  symptoms  that  it  is  difficult  to  say  anything 
positive  as  to  its  duration,  and  as  marked  by  change  of  character, 
attributable  to  simple  brain-failure,  especially  in  negligence  of 
ordinary  duties,  or  indifference  to  them." 

In  this  connection  Folsom  quotes  Brierre  de  Boismont,  who  in 
1860  published  cases  illustrating  the  initial  stage  of  this  disease, 
the  most  striking  of  which  was  that  of  a  man  who  began  thieving 
nearly  eight  years  before  the  diagnosis  of  general  paralysis  was 
made.  He  then  refers  to  Voisin,  in  1879,  and  Luys,  in  1881,  who 
mention  an  obscure  prodromal  period,  "with  marked,  although 
not  distinctive,  mental  symptoms."  Folsom  then  states  that  it 
was  not  until  the  appearance  of  Professor  Ball's  work  in  1883 
and  that  of  Regis  in  1885  that  he  found  in  French  special  medi- 
cal literature  a  clear  statement  of  the  very  insidious  and  obscure 
character  of  the  first  symptoms  of  general  paralysis. 

Folsom  adds  that  since  Sanders,  in  1876,  the  leading  German 
writers  on  diseases  of  the  brain,  especially  Wernicke,  Schiile, 
Krafft-Ebing,  and  Mendel,  "  have  described  the  beginning  of  gen- 
eral paralysis  as  simply  a  change  of  character  quietly  developed, 
and,  later,  so  slight  an  impairment  of  intelligence  as  to  admit  of 
patients  continuing  their  usual  occupations  for  a  considerable  time, 
without  any  indications  of  diminished   mental   power  noticed. 


*  Italics  my  own. 
20 


306  DISEASES   OF   THE   NERVOUS   SYSTEM. 

except  by  those  who  come  in  contact  with  them  most  intunately, 
and  by  them  not  thought  of  as  indicating  disease." 

"  In  Great  Britain,  Savage  in  1884  alludes  to  a  prodromal  stage 
as  attended  with  developed  rather  than  initial  symptoms ;  .  .  • 
and  Sankey,  writing  the  same  year,  fails  to  recognize  so  early  a 
stage.  Clouston,  writing  in  1883,  does  not  describe  the  initial  or 
prodromal  stage.  Mickle  in  1886  mentions  the  prodromic  stage, 
but  with  symptoms  marking  some  progress  in  the  disease,  although 
he  states  that  ^  in  the  history  of  many  a  case  do  we  find  that  some 
moral  or  other  mental  change  in  the  patient,  some  perversion  of 
the  affective  sentiments,  has  been  noticed  long  before  the  acknowl- 
edged onset  of  the  disease ;'  and  in  the  mean  time  it  has  happened 
that  fortunes  have  been  wrecked  or  characters  ruined. 

"  General  paralysis  usually  begins  so  slowly  and  gradually  that 
a  definite  period  for  its  beginning  can  hardly  ever  be  given.  In 
addition,  it  is  often  clear,  at  a  period  when  the  disease  is  already 
fully  developed,  that  certain  early  symptoms,  whose  nature  was 
not  at  first  correctly  recognized,  ought  to  have  been  regarded  as 
the  initial  symptoms."     (Striimpell.) 

My  own  experience  corresponds  with  that  of  the  above-men- 
tioned writers.  In  the  very  few  cases  that  were  under  my  obser- 
vation prior  to  the  development  of  the  general  disease,  I  have 
noticed  several  instances  of  an  obscure  prodromal  stage. 

In  the  case  of  a  lady  whom  I  have  recently  treated  I  had  excel- 
lent opportunities  of  observing  the  correctness  of  this  statement. 
I  have  been  her  family  physician  for  over  twenty  years.  She  has 
been  confined  in  an  asylum  for  the  last  eighteen  months,  the  diag- 
nosis of  her  disease  being  general  paralyds  of  the  insane.  For  a 
year  or  two  prior  to  her  becoming  an  inmate  of  the  asylum,  while 
she  was  an  admitted  leader  of  society,  she  developed,  although 
previously  above  reproach  in  her  moral  character,  salacious  pro- 
pensities which  were  indistinguishable  from  erotomania,  in  con- 
sequence of  which  she  was  in  perpetual  trouble.  I  never  saw  a 
greater  moral  perversion  and  change  developed  without  adequate 
ascertainable  cause  than  in  this  particular  case.  Her  intrigues 
became  so  notorious  as  to  rivet  public  attention  upon  her.  Her 
effrontery  and  importunities  towards  those  of  the  opposite  sex 
finally  became  so  aggressive  and  disgraceful  as  in  two  instances 
to  lead  to  her  arrest.     She  spent  money  lavishly,  and  undertook 


GENERAL   PARALYSIS   OF   THE   INSANE.  307 

long  journeys,  from  St.  Louis  to  New  York  in  one  instance,  and 
from  St.  Louis  to  Canada  in  another,  for  the  gratification  of  her 
nefarious  propensities.  Yet  during  all  this  interval  of  time  not 
the  slisrhtest  mental  defect  could  be  ascertained,  and  she  continued 
to  control  and  to  conduct  most  successfully  an  enormous  estate. 
In  every  other  respect  she  was  seemingly  an  elegant,  refined,  and 
cultivated  lady,  nor  could  a  most  careful  scrutiny  determine  the 
existence  of  symptoms  of  any  stage  of  the  developed  disease. 

It  is  customary  to  divide  this  disease  into  different  periods  or 
stages  :  the  distinction,  however,  is  to  a  certain  extent  an  arbitrary 
one,  because  the  features  of  each  stage  are  not  always  character- 
istic, and  either  period  may  merge  into  the  other. 

Blandford  makes  the  following  division  : 

"  1st.  The  commencement,  or  period  of  incubation. 

"  2d.  The  acute  maniacal  period. 

"  3d.  The  period  of  chronic  mania  lapsing  into  dementia,  with 
utter  prostration  both  of  mind  and  body." 

It  is  a  matter  of  great  regret  that  the  earlier  stages  of  this  dire- 
ful affection  so  frequently  seen  by  the  general  practitioner  often 
remain  utterly  unappreciated  or  even  not  recognized.  Seguin 
most  appropriately  laments  that,  "  even  by  neurologists,  the  diag- 
nosis of  nervous  prostration  or  cerebral  fatigue  is  often  made  and 
a  delusive  prognosis  given.  Rest  and  change  are  advised,  when 
an  active  medication  and  seclusion  from  excitement  should  be 
prescribed." 

The  same  author  further  states  the  symptoms  by  which  an  early 
diagnosis  can  be  made,  as  follows  : 

^'  A  change  in  the  patients  moral  character, — ethical  changes. 
Ethical  development  is  the  last  and  highest  phase  of  action  or 
function  of  the  cerebrum  in  mammals,  and  more  strikingly  in 
man ;  it  is  the  least  instinctive  or  organic  function,  a  sort  of 
delicate  efflorescence ;  and,  consequently,  it  is  not  surprising  that 
it  should  be  the  first  to  retrograde  when  the  cerebrum  is  undergoing 
wide-spread  degeneration  of  slight  degree.  The  alteration,  allow 
me  to  repeat,  is  a  positive  change,  not  an  accentuation  to  a  morbid 
degree  of  the  patient's  previous  faults  of  character,  as  is  observed 
in  various  forms  of  insanity.  Diminished  regard  for  decorum, 
slovenly  habits  in  dress  and  at  table,  slight  deviations  from  truth- 
fulness, an  inclination  to  or  relish  for  ribald  or  obscene  jokes, 


308  DISEASES   OF  THE   NERVOUS   SYSTEM, 

actual  indecency  in  language  and  acts,  indulgence  in  stimulants, 
lascivious  familiarities  and  visits  to  houses  of  prostitution,  etc.,  in 
a  man  who  previously  never  lapsed  in  such  matters,  should  always 
cause  the  greatest  concern  and  lead  to  a  suspicion  of  beginning 
diffused  encephalitis. 

"  Irritability  or  abnormal  anger  might  be  included  in  this  list, 
but  this  increased  reaction  to  external  stimuli  is  a  symptom  more 
characteristic  of  cerebral  neurasthenia,  hysteria,  etc.,  and  seldom 
means  a  change  in  character.  Indeed,  in  my  experience,  good 
nature  and  abnormal  pliability  are  more  frequent  than  irritability 
in  dementia.  The  same  remarks  apply  to  the  abnormal  emotions 
shown  by  victims  of  this  disease  :  they  laugh  or  cry  '  hysterically' 
on  the  slightest  provocation.  This  state,  however,  only  means 
that  we  have  an  abnormally  sensitive  brain  and  diminished  self- 
restraint  before  us, — conditions  fully  as  frequent  in  simple  cerebral 
neurasthenia  as  in  dementia  paralytica. 

"  Not  rarely  these  symptoms  though  appearing  very  early  are 
not  known  to  the  physician,  because  the  patient  cannot  tell  of  them 
and  his  relatives  are  ashamed  to  reveal  them.  They  must  be 
sought  for  ;  consequently,  although  these  ethical  symptoms  are  of 
great  importance,  they  cannot  be  designated  as  striking  or  as  lead- 
ing symptoms,  except  to  the  family  physician,  who,  of  course,  has 
peculiar  opportunities  for  noting  these  changes,  even  before  the 
family  is  alarmed."  (In  a  foot-note  Seguin  states,  "  I  have  some- 
times first  heard  of  these  symptoms  some  time  after  the  consul- 
tation, from  associates  and  friends  of  the  patient,  the  family  having 
carefully  concealed  them.") 

"  Often  it  is  believed  by  laymen  and  physicians  that  the  alco- 
holic and  sexual  irregularities  of  the  patient  are  causes  of  subse- 
quent symptoms,  but  this  is,  most  authorities  agree,  an  erroneous 
and  dangerous  view.  Doubtless  minute  changes  in  the  brain 
precede  the  ethical  degradation. 

"Mental  dulness  and  inaecuracy. — The  patient  often  complains 
of  these  himself;  he  is  becoming  'lazy ;'  mental  exertion  is  onerous ; 
he  feels  dull,  and  even  drowsy,  during  business  hours  ;  he  is  con- 
scious of  doing  everything  slowly  and  laboriously.  He  notes 
mistakes  in  his  calculations,  failures  to  keep  appointments,  and 
other  evidences  of  failing  memory  and  impaired  power  of  atten- 
tion.    In  many  cases — those  in  which  a  slight  degree  of  exaltation 


GENERAL   PAEALYSIS   OF   THE   IXSANE.  309 

appears  early — the  patients  are  unaware  of  these  faults  and  ener- 
getically deny  them.  Yet  it  is  astonishing  how  long  professional 
or  old  habitual  acts  continue  to  be  performed  with  tolerable  exact- 
ness, even  after  many  symptoms  have  appeared.  Such  mental 
operations  as  have  by  long  practice  become  almost  automatic  or 
semi-instinctive  resist  the  disease  remarkably."  (In  a  foot-note 
the  author  continues,  "  I  have  known  of  physicians  who  attended 
to  ordinary  practice  fairly  w^ell  (but  were  suspected  of  drinking 
by  their  clients)  for  a  long  time  after  the  diagnosis  was  clear ;  and 
two  years  ago  I  made  a  diagnosis  of  dementia  paralytica  in  a 
popular  actor,  who  starred  about  the  country  with  diminishing 
success  for  several  months  afterwards.") 

•  Folsom  divides  the  symptoms  of  well-marked  general  paralysis 
into  four  distinct  types  :  "  the  demented  and  paralytic,  the  hypo- 
chondriacal, with  melancholia,  with  exaltation  and  mania."  He 
further  adds,  "  there  are  mixed  cases  in  which  some  or  all  of  these 
forms  occur."  As  before  stated,  I  prefer  the  simpler  classification 
of  Blandford,  Avho  divides  the  disease  mto  three  stages.  I  fully 
agree  with  Folsom  that  the  demented  form  is  the  most  common, 
and  with  Seffuin  that  motor  disturbances  are  often  the  first  com- 
plained  of,  which,  as  observed  by  this  author,  consist  principally 
"  in  difficulty  and  slowness  of  articulation,  awkwardness  of  the 
fingers  for  delicate  movements,  impaired  handwriting,  visible 
tremor,  a  general  loss  of  muscular  force  often  perfectly  evident  to 
the  patient  in  those  cases  where  exaltation  has  not  set  in.  I  have 
notes  of  several  cases  in  which  the  patient  came  to  me  spontaneously 
for  difficult  articulation  (this  appearing  to  him  the  only  symp- 
tom)." Seguin  further  declares  that  "  in  very  rare  cases  impaired 
articulation,  and  slight  tremor  of  the  hands,  are  really  the  first 
symptoms." 

Further  on  in  his  admirable  description,  he  continues,  "  If  there 
is  a  pathognomonic  symptom  in  all  semeiology,  it  is  the  peculiar 
faulty  speech  of  the  early  stage  of  non-delirious  dementia  para- 
lytica. It  is  as  valuable  for  the  diagnosis  of  this  disease  as  ful- 
gurating pains  are  for  that  of  tabes.  Yet  a  similar  speech  (or  at 
least  one  that  seems  like  it)  is  met  with  once  in  a  while  in  a  gen- 
erally tremulous  patient  who  has  not  cortical  degeneration.  So 
rare  is  this  that  I  have  record  of  but  one  example :  so  that  the 
value  of  the  symptom  remains  very  great." 


310  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

In  another  place  Seguin  says,  "  As  tremor  underlies  the  faulty 
speech  (or  dysarthria)  and  the  awkwardness,  allow  me  to  speak  of 
it  at  some  length.  Different  eases  present  tremors  which  I  am  in 
the  habit  of  classifying  as  coarse  and  fine.  Sometimes  it  requires 
the  closest  scrutiny  to  detect  them,  or  they  may  be  almost  choreic 
in  form.  Always  these  tremors  appear  only  on  exertion ;  they 
are  not,  strictly  speaking,  fibrillary  contractions,  nor  are  they  at 
all  like  the  rhythmical  or  quasi-rhythmical  movements  of  paraly- 
sis agitans,  senile  or  alcoholic  trembling.  Consequently  you  will 
have  to  seek  for  this  symptom  by  bidding  the  patient  to  do  certain 
things.  Sitting  quietly,  he  appears  free  from  tremors ;  bid  him 
frown,  and  the  muscles  of  the  upper  part  of  the  face  show  tremu- 
lous action ;  bid  him  show  his  gums,  the  tremor  appears  in  all  the 
lower  facial  muscles ;  bid  him  protrude  the  tongue,  and  that  organ 
appears  filled  with  fine  tremulous  contractions,  or  is  agitated  as  a 
whole  by  coarser  tremors ;  make  the  patient  hold  out  his  hands, 
and  various  degrees  of  non-rhythmical  tremor  are  apparent  to  your 
eye  or  to  your  fingers  (if  you  hold  his  fingers  within  yours). 
Tell  him  to  speak,  and  the  aerial  waves  are  broken  by  the  irregular 
muscular  contraction,  producing  various  forms  of  faulty  articu- 
lation. Emotion,  which  in  almost  all  persons  is  accompanied  by 
unconscious  muscular  movements  in  various  parts,  also  brings  out 
the  tremors.  At  once  when  the  patient  begins  to  tell  you  his 
ailments  or  replies  to  your  questions,  the  faulty  speech  reveals  the 
tremors,  and  to  the  experienced  ear  foretells  the  man's  doom." 

Seguin  lays  particular  stress  upon  the  statement  that  the  fun- 
damental character  of  the  speech  in  paresis  is  "non-rhythmic 
vibration,"  which  leads  to  a  jerky,  irregular  utterance,  and  an 
increased  muscular  tremor,  causing  the  indistinct  sounds  with 
omission  of  syllables  in  long  words.  Seguin  asserts  that  it  is  a 
mistake  to  regard  this  omission  of  syllables  as  the  characteristic 
fault,  as  it  is  not  present  in  the  early  period  of  the  disease.  The 
speech  in  paresis,  he  says,  is  not  only  tremulous  or  jerky,  but 
often  slow ;  some  syllables  are  spoiled, — some  are  omitted  from 
lono;  words.     No  other  disease  causes  this. 

Starr,  in  his  work  on  "Familiar  Forms  of  Nervous  Disease" 
(1891),  says,  "The  onset  of  this  disorder  is  protean  in  its  mani- 
festations. The  earliest  symptoms  may  be  either  physical  or  men- 
tal or  both.     Tremor  of  the  fingers  and  of  the  hand  in  writing ; 


GENEEAL   PARALYSIS   OF   THE   INSANE.  311 

fibrillary  tremor  of  the  tongue  and  lips  ;  slight  difficulty  in 
the  pronunciation  of  certain  words,  such  as  occur  in  the  phrase 
"  Grief  brings  frightful  dreams ;"  overaction  of  the  occipito- 
frontalis  muscle ;  slight  irregularity  or  inequality  of  the  pupils, 
myosis,  or  loss  of  the  pupillary  reflexes ;  exaggeration  of  the 
wrist-,  elbow-,  and  knee-jerks  (rarely  diminution) :  all  these  are 
among  the  earliest  somatic  characteristics.  Later  these  become 
more  and  more  pronounced,  until  diagnosis  is  inevitable." 

The  temperature  in  general  paralysis  is  higher  than  in  health. 
It  is  rarely  lower.  Folsom  reports  that  in  the  only  extremely 
rapid  cases  he  ever  treated  (two  months  in  all)  it  was  97°  F.  or 
thereabout  for  a  number  of  days,  and  then  rapidly  rose  to  103° 
and  104°,  where  it  remained  almost  until  death.  He  very  truly 
states  that  after  the  congestive,  epileptiform,  and  apoplectiform 
attacks  it  rises  from  two  to  seven  degrees,  and  remains  high  for 
a  considerable  time.  Folsom  divides  the  leading  symptoms  of 
general  paralysis  of  the  insane  into  (1)  vaso-motor,  (2)  mental, 
and  (3)  physical. 

This  view  is  of  great  importance,  if  we  admit  Meynert's  theory 
that  preceding  and  causing  the  diffused  cortical  encephalitis  there 
is  a  functional  vaso-motor  disorder  which  he  considers  curable. 

According  to  Folsom,  the  vaso-motor  symptoms  are  represented 
by  arterial  paralysis,  changes  in  the  cerebral  circulation,  diminished 
arterial  tension,  attacks  of  vertigo,  dizziness,  or  faintness,  con- 
fusion, incoherence,  and  dementia,  elevation  or  depression  of  the 
temperature,  frequent  attacks  of  congestion  or  transient  cerebral 
ansemia,  emotional  disturbances,  epileptiform  or  apoplectiform 
seizures,  with  or  without  temporary  loss  of  muscular  power, 
monoplegic,  hemiplegic,  or  paraplegic  character,  bed-sores,  skin- 
affections,  cyanosis,  neuro-paralytic  hypersemia  of  the  lungs,  blad- 
der, and  intestines,  cold  feet,  cedema  of  the  skin  and  local  sweat- 
ings, and  variations  in  the  mental  state.  As  the  disease  advances 
there  is  an  increase  in  the  loss  of  power  of  control  and  in  the 
loss  of  mental  power,  the  two  symptoms  making  progress  side 
by  side. 

Folsom  further  states  that  "  after  the  prodromal  period  has 
passed  the  mental  impairment  increases,  so  that  the  judgment, 
memory,  power  of  attention,  and  expression  grow  progressively 
worse ;   and  this  impairment  constitutes  the  only  characteristic 


312  DISEASES   OF   THE   NERVOUS  SYSTEM. 

mental  state  universally  present  in  all  stages  of  general  paralysis 
of  the  insane, — namely,  progressive  dementia."  The  impairment 
of  the  sense  of  right  and  wrong  becomes  quite  marked ;  the  patient 
loses  the  sense  of  property  and  ownership.  In  no  other  disease 
could  the  reported  case  occur  of  a  man,  to  outward  appearance 
well,  going  up  to  a  policeman  and  asking  his  assistance  in  rolling 
off  a  barrel  of  liquor  which  belonged  to  some  one  else,  and  which 
he  meant  to  appropriate.  For  this  reason,  what  seem  to  be  thefts 
are  very  common,  and,  although  by  that  time  there  is  striking 
mental  impairment,  it  may  not  be  obvious  to  every-day  people. 
Almost  every  other  moral  obliquity  occurs,  particularly  a  tendency 
to  drunkenness  and  to  every  possible  violation  of  the  proprieties 
and  laws  regarding  property  and  the  sexual  function. 

Lastly,  there  are  strange  delusions,  consisting  of  remarkable 
exaltations,  a  curious  and  overweening  self-esteem.  A.  proneness 
to  extraordinary  exaggeration  and  extravagant  ideas  is  rarely 
absent.  Indeed,  it  seems  impossible  for  the  patient  to  make  the 
least  statement  without  its  being  greatly  exaggerated.  These  last 
peculiarities  have  caused  the  affection  to  be  termed  by  the  French 
manie  de  grandeur,  or  manie  d' exaltation.  Persons  ajBBicted  with 
this  disease  always  entertain  a  conviction  of  their  own  importance 
and  power,  and  invariably  endeavor  to  impress  this  upon  others 
with  whom  they  associate.  I  will  cite  you  a  few  instances  which 
happened  in  my  own  experience. 

I  have  now  under  my  care  a  man  who  labors  under  the  most 
remarkable  self-exaltation.  He  imagines  that  he  is  the  wealthiest 
man  in  the  world,  that  he  actually  possesses  all  the  gold  in  exist- 
ence. With  him  money  is  of  no  value  :  he  is  immensely,  incom- 
parably rich,  and  states  that  if  the  waters  of  the  Atlantic  were 
withdrawn  and  its  bed  exposed,  it  could  not  contain  all  his  gold. 
He  imagines  that  all  the  civilized  world  recognizes  in  him  the 
greatest  living  railroad  king  ;  and,  as  he  comes  from  Memphis,  he 
considers  that  city  the  great  centre  of  the  globe.  In  its  vicinity, 
he  says,  there  are  immense  mountains  of  iron,  which  he  purchased 
years  ago.  This  enables  him  to  build  railroads  in  all  directions, 
and  he  purposes  to  transport  upon  them  all  the  larger  cities  of  the 
United  States  to  Memphis.  He  has  now  in  course  of  construc- 
tion, in  Liverpool,  immense  derricks,  by  means  of  which  he  will 
raise  the  entire  city  of  St.  Louis  into  the  air  and  place  it  upon  a 


GENEEAL   PARALYSIS   OF   THE   INSANE.  313 

line  of  railroad  he  is  building  for  the  purpose,  which  will  be  not 
merely  an  air-line  road,  but  three  miles,  at  least,  above  the  surface 
of  the  earth.  He  is  quite  certain  of  being  able  to  move  our  entire 
metropolis  in  less  than  thirty  seconds.  His  resources  are  inex- 
haustible. His  mountains  of  silver  he  claims  to  have  received 
from  God  Almighty  as  an  acknowledgment  of  the  fact  that  he 
had  lent  Him  a  large  sum  of  money  upon  some  previous  occa- 
sion. This  man  is  as  firmly  convinced  of  the  truth  of  these 
ludicrous  ideas  as  you,  gentlemen,  are  of  your  existence.  His 
delusion  is  the  more  striking  in  view  of  the  fact  that  he  is  very 
poor,  and  not  even  at  liberty,  but  in  an  asylum. 

An  architect  under  my  care  some  years  ago  had  also  a  very 
remarkable  idea  of  his  own  greatness.  '  He  was  willing  to  extend 
favors  to  Almighty  God,  and  had  in  contemplation  the  con- 
struction of  a  "  temple  for  the  world."  He  had  made  drawings 
which  were  really  beautiful  and  complete  in  detail.  He  stated 
that  to  this  temple  all  the  people  of  the  earth  would  come  to 
bend  the  knee.  It  would  be  replete  with  gold,  silver,  and  mosaic ; 
there  being,  in  fact,  more  of  the  former  than  all  the  nations  of  the 
world  could  supply,  he  himself  having  ample  means  of  furnishing 
inexhaustible  quantities.  To  show  you  the  immense  idea  of  gran- 
deur which  had  taken  possession  of  this  man,  he  said  that  on  the 
day  of  the  inauguration  of  his  temple  the  whole  civilized  and 
barbarian  world  would  be  present  to  celebrate  the  occasion.  All 
of  these  would  occupy  the  temple,  together  with  all  the  illustrious 
dead  of  past  ages;  and  yet  the  temple  was  not  to  cover  more 
ground  than  the  St.  Louis  County  Court-house  !  The  assembled 
multitudes  would  all  come  to  worship  the  statue  of  the  greatest 
of  living  men, — himself.  His  statue  was  to  be  of  gold  and  on  an 
eminence  from  which  it  could  be  seen  by  all  the  world.  On 
Christmas-day  and  the  Fourth  of  July  he  would  mount  the 
eminence  in  person,  so  that  everybody  might  adore  and  venerate 
him. 

We  treated  for  many  years  a  case  of  paralytic  dementia  in 
which  the  patient  presented  a  very  singular  and  interesting  de- 
lusion. He  was  a  very  learned  man,  and  had  been  for  a  long  time 
a  successful  professor  of  chemistry.  His  body  presented  an  un- 
usually large  crop  of  moles  and  warts,  to  each  of  which  he  attached 
a  mythological  or  astronomical  name.     One  he  would  call  Mars, 


314  DISEASES   OF   THE  NERVOUS  SYSTEM. 

a  second  Yenus,  a  third  Jupiter,  etc.  He  had  written  in  Latin 
and  Greek  upon  the  walls  of  his  room  many  descriptions  of  the 
relationship  which  these  growths  bore  to  his  sacred  personality, 
constituting  quite  a  long  and  learned  history.  By  grouping  them 
together  and  attaching  thereto  long  algebraic  formulae,  he  proved, 
to  his  own  satisfaction  at  least,  that  he  was  the  God  of  Gods,  the 
ruler  of  the  universe.  For  years  he  never  varied  in  the  details 
of  these  descriptions,  and  it  was  quite  interesting  to  listen  to  him. 
He  was  a  splendid  classical  scholar,  and,  singular  to  say,  notwith- 
standing the  character  of  his  disease,  his  memory  in  some  respects 
was  extraordinary.  He  could  give  long  and  most  accurate  reci- 
tations from  Virgil,  Horace,  and  Homer. 

Such  conceptions  are  peculiar  and  characteristic.  One  man 
may  believe  that  he  is  the  greatest  of  living  generals ;  another, 
that  he  controls  the  universe,  and  that  upon  his  care  and  attention 
the  rotation  of  the  earth  depends. 

It  has  been  a  matter  of  much  discussion  whether  the  symptoms 
of  the  disease  succeed  one  another  in  a  certain  regular  order, — 
whether  the  paralysis  of  the  organs  of  speech,  or  the  delusions, 
precede  the  difficulty  in  walking,  or  the  reverse.  This  question 
has  not  been  definitely  settled,  and  does  not  intimately  concern  you 
as  students.  In  my  own  experience  I  have  generally  found  the 
mental  symptoms  to  be  first  developed,  and  afterwards  the  para- 
lytic phenomena  producing  difficulty  in  articulation  and  motion. 
This  impediment  in  speech  is  more  readily  observed  when  the 
patient  is  engaged  in  animated  conversation,  and  the  gait  is  very 
similar  to  that  of  progressive  locomotor  ataxia.  There  seems  to 
be  a  similar  want  of  muscular  co-ordination  :  the  patient  does  not 
drag  his  feet  as  in  hemiplegia,  but  staggers,  and  appears  to  be  in 
danger  of  falling.  An  unequal  dilatation  of  the  pupils,  without 
being  a  constant  symptom,  is  rarely  absent.  Epileptiform  and 
apoplectiform  attacks  are  frequent. 

Folsom  observes,  "  I  have  usually  found,  when  I  had  oppor- 
tunities to  investigate,  that  in  the  history  of  general  paralysis  the 
prodromal  period,  although  not  at  the  time  considered  important 
as  such,  is  remembered  as  having  existed.  But,  of  the  very  large 
number  of  cases  which  I  have  seen  in  the  last  ten  years  presenting 
symptoms  of  cerebral  asthenia  or  general  neurasthenia,  I  have  not 
found,  even  in  the  many  who  neglected  treatment,  a  single  case 


GENERAL   PARALYSIS   OF   THE   IXSAN'E.  315 

of  general  paralysis  follow ;  and  in  the  three  or  four  cases  where 
I  ventured  to  provisionally  make  that  diagnosis,  either  I  was  mis- 
talven  or  a  recovery  followed  with  but  very  little  treatment  but 
rest.  Of  numerous  cases  with  the  symptoms  of  cerebral  hyper- 
semia  which  are  so  common  in  brain-tire  from  over-strain,  I  have 
not  seen  one  develop  into  general  paralysis,  nor  have  I  known  a 
case  of  general  paralysis  with  such  antecedent.  In  the  prodromal 
period  the  best  that  we  can  do,  until  our  means  of  diagnosis  vastly 
improve,  is  to  indicate  a  certain  danger  signal  by  which  to  warn 
our  patients. 

"  When  to  vaso-motor  indications,  whether  slight  or  not,  sym- 
metrical motor  symptorns  are  added,  the  initial  stage  begins,  and 
its  appearance  is  most  insidious.  There  is  a  little  general  muscular 
weakness,  with  some  failure  in  concentration  and  adjusting  skill. 
The  occasional  lapses  from  a  former  standard  of  living,  of  self- 
respect,  and  perhaps  decency  or  honor,  if  they  occur,  are  regarded 
as  ethical  rather  than  as  requiring  medical  advice.  The  inex- 
plicable change  in  personality,  in  character  and  conduct,  is  simply 
not  explained.  The  diminished  physical  power  or  endurance  is 
thouffht  fatigue.  The  muscular  incoordination  and  embarrassment 
of  speech  are  so  slight  as  to  rarely  admit  of  easy  detection.  The 
initial  signs  of  general  paralysis  are  of  brain-failure.  They  may 
be  recognized  in  a  large  proportion  of  cases,  at  least  in  those  per- 
sons whose  muscles  and  brains  are  highly  organized.  In  profes- 
sional and  business  men  a  less  degree  of  impairment  is  recognizable 
than  in  mechanics ;  in  routine  employments  a  large  degree  of 
deterioration  may  be  unnoticed.  In  day-laborers  an  early  diag- 
nosis is  simply  impossible."  * 

Myosis  is  a  most  common  symptom :  in  fact,  the  pupils  are  so 
small,  Seguin  says,  "as  to  deserve  the  appellation  of  pin-head 
pupils  ;  shading  the  eyes  or  placing  the  patient  in  a  dark  room 
causes  no  expansion.  They  are  in  a  state  of  spasm,  as  German 
writers  call  it." 

Inequality  of  the  puj)ils  is  almost  always  present.  Optic  neu- 
ritis is  sometimes  observed. 

The  patient's  manner  is  often  confused ;  from  my  own  expe- 
rience I   can  fully  confirm  Seguin's  graphic  description  of  it : 

*  Folsom,  Some  Points  regarding  General  Paralysis,  May,  1891. 


316  DISEASES   OF   THE   NERVOUS  SYSTEM. 

"  The  patient  seems  confused  in  taking  a  chair,  or  trying  to  leave 
the  room ;  he  looks  at  various  objects  in  your  office  regardless  of 
the  fact  that  you  are  questioning  him ;  he  looks  from  his  friends 
to  you  in  a  stupid,  helpless  manner,  and  tolerates  that  they  answer 
for  him.  Frequently  he  interrupts  his  friends  to  deny  the  symp- 
toms they  relate.  In  showing  his  tongue  he  opens  his  mouth 
enormously,  and  makes  an  extensive  absurd  grimace.  When 
once  seen,  it  is  a  behavior  never  to  be  forgotten."  Seguin  also 
remarks,  "  Two  years  ago  I  saw  a  perfectly  lucid  patient  pre- 
senting tremors,  imperfect  speech,  unequal  pupils,  conscious  failure 
of  memory,  etc.  On  taking  leave  of  him  he  put  the  fee,  which 
his  wife  had  handed  him  to  give  me,  into  his  own  pocket,  and  at 
the  door  shook  hands  with  her.  The  poor  fellow,  who  has  since 
died,  was  instantly  aware  of  these  errors,  and  laughed  heartily  at 
them." 

In  explanation  of  the  psychological  mechanism  of  these  symp- 
toms, the  last-named  author  observes  that  the  patient's  perceptions 
are  fleeting  and  imperfect,  his  will-power  diminished,  his  power 
of  attention  impaired,  and  that  he  labors  under  a  sense  of  unreality 
and  uncertainty. 

Regarding  the  optimistic  delusions,  too  much  importance  should 
not  be  attached  to  them ;  in  rare  instances  they  may  never  appear, 
and  certainly  they  should  not  be  considered  as  pathognomonic. 
It  should  also  be  remembered  that  maniacal  excitement,  epilepti- 
form and  apoplectiform  seizures,  are  usually  developed  only  in  the 
more  advanced  stages  of  the  disease. 

Reflexes  are  generally  exaggerated. 

I  herewith  present  a  synopsis  of  symptoms  from  which,  Seguin 
maintains,  "  an  early  diagnosis  of  dementia  paralytica  can  be  made 
by  the  practitioner  ;  nay,  should  be  made  by  him. 

(1)  "  A  positive  diagnosis  can  be  made,  I  believe,  from  the 
speech  alone  ;  but  perhaps  it  is  too  much  to  ask  the  general  prac- 
titioner to  risk  so  much  on  one  symptom.  Impaired  speech,  with 
unequal  motionless  pupils,  high  reflexes,  and  slight  mental  symp- 
toms, should,  however,  oblige  the  physician  to  make  a  diagnosis 
and  remove  the  imtient  from  business. 

(2)  "  Fixed,  small  or  unequal  pupils,  with  changes  in  character, 
increased  reflexes,  and  confusion  in  manner,  should  lead  to  a  sus- 
picion of  dementia  paralytica.     Even  the  small  fixed  pupils  alone 


GENERAL   PARALYSIS   OF  THE   INSANE.  317 

should,  I  think,  excite  suspicion,  and  lead  to  careful  observation 
of  the  patient. 

(3)  "  jNIental  slowness  and  inaccuracy,  with  any  one  of  the  other 
symptoms  referred  to,  should  cause  a  strong  suspicion  of  incipient 
'  paresis.'  The  same  is  true  of  the  inexplicable  changes  in  the 
moral  character  of  a  subject  above  twenty  years  of  age. 

(4)  "  Dementia  paralytica  is,  I  might  add,  much  more  frequent 
among  women  than  is  generally  held  by  authorities.  They  can 
more  easily  cover  up  signs  of  mental  failure,  and  they  seldom 
exhibit  exaltation.  Guided  by  the  points  I  have  given  as  of 
great  diagnostic  value,  you  will  be  able  to  recognize  a  good  many 
female  cases. 

(5)  "  A  general  character  of  great  value  is  the  gradual  slow 
onset  of  symptoms.  When  an  adult  rapidly  becomes  demented 
(foolish  in  manner,  inattentive  to  his  person,  even  to  the  point 
of  not  controlling  his  evacuations),  has  unequal  pupils,  and  large 
quasi-choreic  ataxic  tremors  with  early  convulsive  seizures,  it  is 
possible  that  the  case  is  one  of  cerebral  syphilis,  which  may  be 
cured  by  heroic  treatment. 

(6)  "  You  should  not  be  discouraged  in  your  diagnosis  by  an 
apparent  return  to  health  after  a  few  months,  because  extraor- 
dinary reuaissions,  lasting  several  months,  occur  in  the  course 
of  dementia  paralytica,  yet  even  in  these  remissions  a  critical 
examination  almost  always  reveals  traces  of  the  physical  symp- 
toms." 

In  the  last  point  noted,  Seguin  is  referring  to  the  wonderful 
remissions  in  the  physical  and  mental  symptoms  which  consti- 
tute so  marked  a  feature  in  many  cases  of  this  disease.  These 
remissions  may  last  from  six  months  to  a  year  or  two.  Most  of 
tlie  reported  cures  of  general  paralysis  are  nothing  but  remissions 
of  this  disease,  by  Avhich  the  most  experienced  observer  may  be 
misled. 

The  physical  symptoms  of  general  paresis  consist  in  impaired 
control  of  the  muscular  system,  diminished  power  of  co5rdination, 
ending  sooner  or  later  in  complete  paralysis. 

The  muscles  of  the  eye,  of  the  fingers,  of  articulation,  first 
exhibit  the  unmistakable  evidences  of  progressive  ataxic  impair- 
ment. The  gait  of  the  patient  soon  becomes  aifected  ;  disturbances 
of  locomotion  from  want  of  muscular  coordination  are  but  too 


318  DISEASES   OF  THE   NERVOUS   SYSTEM. 

apparent,  and  are  sometimes  associated  with  malaise  and  muscular 
pain.  The  patient  frequently  attracts  attention  by  a  staggering 
gait.  Many  author's  have  observed  the  close  relationship  in  some 
symptoms  between  locomotor  ataxia  and  dementia,  paralytica.  The 
muscular  movements  are  tremulous  and  uncertain ;  the  strength  is 
more  or  less  diminished,  and  may  be  particularly  manifested  in 
spurts  of  very  unequal  duration.  The  handwriting  becomes  very 
tremulous  and  illegible ;  the  articulation  becomes  thicker,  more 
stammering,  and  unintelligible ;  the  gait  more  shuffling,  more 
staggering,  and  straddling. 

Folsom  truly  observes  (after  describing  the  physical  conditions 
which  I  have  just  quoted)  that  "  the  voice,  for  instance,  may  be 
loud  and  forcible,  but  the  coordination  sufficient  for  only  a  short 
explosive  utterance  of  one  syllable,  and  then  quite  an  interval 
elapses  before  force  can  be  concentrated  for  the  next.  Progressive 
muscular  paresis  becomes,  finally,  absolute  paralysis." 

General  paresis,  as  far  as  heredity  is  concerned,  has  not  such 
close  relations  with  mental  diseases  as  insanity  in  general.  Folsom 
states  that  "  of  cases  of  general  paralysis  without  a  previous  his- 
tory of  syphilis  (and  the  same  statement  is  true  in  a  less  degree 
of  persons  who  have  had  syphilis)  the  vast  majority  occur  in 
families  in  which  there  have  been  cases  of  insanity,  epilepsy,  or 
apoplexy."  It  is  found  particularly  among  brain-workers,  and 
we  agree  with  Folsom  that  it  is  not  only  most  frequent  in  the 
stronger  sex,  but  selects  strong  individuals  in  the  prime  of  life, 
between  the  ages  of  thirty-five  and  fifty.  Alcoholic  and  sexual 
excesses  are  considered  very  common  causes.  Mental  shocks  and 
emotional  strain  have  their  influence  as  etiological  factors. 

Folsom,  in  a  monograph  on  "The  Early  Stage  of  General 
Paralysis,  1889,"  states  that  from  five  per  cent,  to  nearly  one 
hundred  per  cent,  of  general  paralytics  are  reported  by  various 
observers  as  having  previously  had  syphilis.  In  Mendel's  cases 
of  general  paralysis  the  percentage  of  syphilitics  was  seventy-five. 

Folsom  concludes  that  at  least  two-thirds  of  general  paralytics 
have  previously  had  syphilis  :  he  continues,  "  If  we  assume,  there- 
fore, that  one  person  in  ten  in  a  certain  adult  male  community 
(from  the  age  of  twenty-one  upward)  has  had  syphilis,  it  appears 
that  an  individual  having  ever  suffered  from  that  disease  has  not 
far  from  twenty  times  as  many  chances  of  becoming  a  general 


GENEEAL   PARALYSIS   OF   THE   IXSANE.  319 

paralytic  as  the  rest  of  the  community."  He  further  observes  that 
there  are  two  reasons  why  general  paralysis  cannot  be  accepted 
as  being  a  stage  of  syphilis, — first,  because  the  usual  remedies  for 
syphilis  are  not  of  the  slightest  benefit,  and,  secondly,  because  there 
is  no  known  method  of  certainly  differentiating,  either  clinically 
or  post  mortem,  cases  with  a  previous  history  of  syphilis  from 
cases  without  it. 

As  regards  the  diagnosis  of  general  paralysis,  I  again  refer  you 
to  Seguin's  admirable  synopsis  of  diagnostic  facts,  to  which  may 
be  added  Folsom's  statement,  that  "  the  earliest  signs  of  general 
paralysis  are  of  the  slightest  possible  brain-failure  ;  that  the  very 
essence  and  nature  of  general  paralysis  imply  and  involve  mental 
symptoms  in  some  degree,  and  some  motor  impairment,  however 
slight,  even  if  only  judged  by  the  test  of  a  minute  examination 
of  what  the  patient  can  do,  and  how  well  or  how  ill  he  does  it ; 
the  change  in  personal  traits  or  character,  and  the  peculiar,  apa- 
thetic, indifferent,  unconscious  quality  of  the  mental  impairment, 
in  uncomplicated  cases,  are  unlike  anything  else." 

We  cannot  agree  with  Folsom,  however,  as  opposed  to  what  has 
already  been  quoted  from  Seguin's  graphic  description,  that  "  the 
speech  may  be  not  noticeably  affected  to  the  family,  and  may  be 
only  like  that  of  a  person  with  lips  chilled  by  the  frost  or  slightly 
under  the  influence  of  wine." 

The  prognosis  of  this  implacable  affection  may  be  summed  up 
in  the  word  Jatality. 

Folsom  states  it  in  these  words  :  "  From  the  galloping  cases  of  a 
couple  of  months  to  those  slowly  advancing,  w^th  long  remissions, 
over  twenty  years,  the  average,  including  prodromal  period,  is 
probably  not  far  from  five  (perhaps  six)  years.  Collected  from 
asylum  statistics  it  is  given  as  from  two  to  three  years." 

PATHOLOGY   AND   MOPvBID   ANATOMY. 

Meynert  asserts  that  preceding  and  causing  the  diffused  cortical 
encephalitis  there  is  a  functional  vaso-motor  disorder  which  he 
considers  curable. 

"  General  paralysis  of  the  insane  is,  according  to  jMendel,  fol- 
lowing Rokitansky's  idea,  a  connective-tissue  disease,  affecting 
the  nerve-cells  and  tissues  secondarily,  while  Tuczek  and  Wer- 
nicke think  that  the  primary  disease  is  of  the  nerve-elements, — a 


320  DISEASES   OF   THE   NERVOUS  SYSTEM. 

diffused  interstitial  cortical  encephalitis  on  the  one  hand,  or  a  dif- 
fused parenchymatous  cortical  encephalitis  on  the  other.  There 
is  also,  in  well-marked  cases,  atrophy  of  the  white  substance,  due, 
according  to  the  general  opinion  of  pathologists,  to  primary  inter- 
stitial encephalitis  ending  in  sclerosis."     (Folsom.) 

"In  the  majority  of  cases  there  is  pachymeningitis, — also  lepto- 
meningitis, with  adhesions  to  the  cortex,  especially  of  the  anterior 
and  antero-lateral  portions,  so  firm  that  the  arachnoid  cannot  be 
removed  without  tearing  off  portions  of  the  brain  ;  but  it  is  some- 
times scarcely  observed,  and  may  be  no  more  than  is  found  in 
persons  dying  simply  of  old  age.  The  pia  may  be  thickened  at 
certain  points,  opaque,  and  without  adhesions.  Ependymitis  is 
usual."     (Folsom.) 

As  we  have  long  known,  lead-poisoning  often  attacks  the  central 
nervous  system,  and  results  in  epileptiform  attacks,  mental  im- 
pairment, muscular  weakness,  and  paralysis.  Some  very  graphic 
descriptions  of  this  morbid  condition  have  been  contributed  by 
Dr.  Todd  ("  Clinical  Lectures  on  Paralysis,  Disease  of  the  Brain, 
and  other  Affections  of  the  Nervous  System,"  published  in  1855), 
and  also  by  many  more  recent  writers,  especially  by  Folsom  in 
his  article  on  "  Mental  Diseases,"  in  Pepper's  "American  System 
of  ]\Iedicine." 

This  last  writer  states  that  "  chronic  endarteritis,  arterio-scle- 
rosis,  atheroma  of  the  cerebral  arteries,  may  be  so  diffused  as  to 
simulate  general  paralysis,  especially  in  drunkards  and  syphilitics, 
but  the  symptoms  do  not  advance  in  the  manner  characteristic  of 
that  disease." 

Referring  to  the  fact  that  "  multiple  cerebro-spinal  sclerosis  of 
the  descending  form  may  sometimes  be  confounded  with  general 
paralysis  while  the  symptoms  are  obscure,"  he  especially  cautions 
physicians  against  mistaking  the  symptoms  of  lead  toxaemia  for 
those  of  the  early  stage  of  general  paralysis,  directing  attention, 
moreover,  to  the  absence  of  ataxic  symptoms  in  lead-poisoning 
and  their  regular  progress  in  the  latter  form  of  disease. 

In  cases  of  lead  paralysis,  he  calls  attention  to  the  importance 
of  ascertaining  the  presence  of  lead  in  the  urine,  and  to  the 
marked  improvement  from  the  use  of  iodide  of  potassium,  tonics, 
and  electricity. 

I  would  add  that  the  history  of  the  case,  the  existence  of  prior 


GENERAL   PARALYSIS   OF   THE   INSANE.  321 

attacks  of  colica  pidonum,  and  the  presence  of  the  "gingival 
line"  are  points  not  to  be  overlooked  in  the  differential  diagnosis. 
Folsom  appropriately  calls  attention  to  the  fact  that  "  chronic 
and  persistent  alcoholism  is  always  attended  with  some  mental 
impairment,  which  may  so  resemble  the  dementia  of  general  pa- 
ralysis, with  marked  moral  perversion,  mental  exaltation,  grand 
delusions,  muscular  tremor,  ataxic  symptoms,  and  impaired  mus- 
cular power,  as  to  make  the  diagnosis  doubtful  for  several  months, 
until  removal  of  the  cause  (alcohol)  in  the  course  of  time  causes 
the  symptoms  to  so  abate  as  to  make  the  real  character  of  the 
disease  evident." 

TREATMENT. 

Rest  and  general  hygienic  measures  should  be  enforced.  Ergot 
and  the  careful  use  of  the  bromides  may  be  of  some  slight  use 
and  transient  effect  in  the  earlier  stages.  Enemas  and  laxatives, 
especially  rhamnus  frangula,  should  be  resorted  to  when  the 
bowels  are  constipated.  Chloral  and  the  bromides  are  of  great 
service  in  controlling  the  epileptiform  attacks.  Conium,  hyoscy- 
amine,  and  hydrobromate  of  hyoscine  may  be  judiciously  used  to 
control  the  maniacal  exacerbations.  Iodide  of  potassium  has  its 
advocates.  Many  of  these  patients  must  necessarily  be  sent  to 
asylums,  as  they  may  at  any  moment  become  very  dangerous. 
The  treatment  of  general  paralysis  is  at  best  most  unsatisfactory. 

Ergotinine  in  general  paralysis. — Several  authors  refer  to  ergot 
in  the  treatment  of  general  paralysis,  but  Christian  reports  quite 
marked  success  in  checking  the  convulsive  seizures  of  this  dis- 
ease by  hypodermatic  injections  of  ergotinine.  He  employs  one- 
sixtieth  of  a  grain  (0.001  gramme)  in  solution,  and  has  found  one 
or  two  injections  sufficient  to  check  the  convulsions.* 

In  cases  with  syphilitic  histories,  it  is  well  to  resort  to  specific 
treatment  and  give  the  patient  the  benefit  of  any  doubt.  Iodide 
of  potassium  in  heroic  doses,  and  mercurials,  should  be  essayed. 
A  combination  of  half  a  grain  of  protiodide  of  mercury  with  a 
quarter  of  a  grain  of  extract  of  opium,  as  suggested  by  my  friend 
Dr.  W.  A.  Hardaway,  of  this  city,  I  have  found  very  service- 
able in  many  syphilitic  affections  of  the  nervous  system,  given 
morning  and  evening. 

*  Brush,  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 

21 


322  DISEASES   OF   THE   NERVOUS  SYSTEM. 


SURGICAL   INTEEFERENCE   IN   GENERAL   PARALYSIS. 

"  A  recent  issue  of  the  American  Journal  of  Psychology  contains 
a  number  of  papers  discussing  the  question  of  surgical  interference 
in  general  paralysis.  It  is  stated  that  to  Dr.  T.  C.  Shaw  belongs 
the  credit  of  making  the  first  attempt,  surgically,  to  alter  the 
course  of  this  disease.  To  his  mind  the  pathological  appearances 
in  general  paralysis  pointed  to  an  irritative,  probably  inflam- 
matory, process  in  the  upper  layers  of  the  convolutions.  The 
theory  of  the  operation  was  that,  by  producing  an  alteration  in 
the  existing  state  of  the  morbid  process,  a  new  and  nutritive 
process  might  be  set  up.  On  the  theory  of  nerve-stretching,  he 
proposed  to  stretch  the  brain,  by  giving  it  more  space  in  which  to 
expand,  allowing  it  to  relieve  itself  of  the  increased  arterial  press- 
ure shown  by  the  sphygmograph  to  be  one  of  the  early  conditions 
of  general  paralysis.  Shaw  considers  that  the  operation  in  his 
case  was  justified  by  the  success  attending  it,  as  the  patient's 
general  condition  improved,  although  the  prominent  bulbar  symp- 
toms remained.  Dr.  Batty  Tuke's  patient  also  improved  for  a 
short  time  after  the  operation,  but  then  relapsed.  His  case  was 
further  advanced  than  Shaw's,  but  he  felt  that  the  results  had 
warranted  the  operation.  The  pressure  theory,  according  to  Tuke, 
makes  it  certain  that  obstructed  lymph  may  make  its  way  but 
imperfectly  by  natural  channels  to  the  pia-matral  space,  and 
become  diffused  through  the  tissues,  injuring  and  displacing  cells 
and  fibres  and  impairing  their  functional  activity.  The  operation, 
by  permitting  a  healthy  action  of  the  lymphatics  and  blood- 
vessels, stays  the  process  of  sclerosis. 

"  Rivington,  however,  considers  that  the  entire  mass  of  patho- 
logical evidence  is  absolutely  contradictory  of  such  a  theory  as 
this,  and  that  the  typical  cell  degenerations  found  in  general 
paralysis  are  not  such  as  may  be  expected  to  follow  simple  excess 
of  fluid-pressure,  but  are  rather  true  degenerations,  due  to  acute 
interstitial  anomalies,  with  no  notable  differences  between  the 
changes  through  which  the  cells  pass  and  those  in  senile  atrophy, 
and  that  there  is  no  excess  of  fluid  in  the  first  stage,  while  the 
second  stage  is  one  of  extraordinary  development  of  the  lymph 
connective  system  of  the  brain  with  a  parallel  degeneration  and 
disappearance  of  nerve-elements,  the  axis-cylinders  of  which  are 


GENERAL   PARALYSIS   OF   THE   INSANE.  323 

denuded.  In  the  first  stage,  then,  the  only  one  in  which  an  oper- 
ation would  be  justifiable,  there  is  no  excess  of  fluid,  and  in  no 
stage  is  the  fluid  of  more  than  secondary  importance.  The  final 
deductions  from  a  survey  of  the  evidence  in  these  cases  are  that 
the  pathology  upon  which  the  operations  were  founded  is  opposed 
to  all  the  best  knowledge  on  the  subject,  and  that  the  collation  of 
two  cases  warrants  nothing  so  clearly  as  the  opinion  that  little 
good  can  be  expected  from  the  operation  of  trephining  in  general 
paralysis. 

"  In  this  connection  it  may  be  mentioned  that  a  number  of 
cases  have  been  reported  by  Burckhardt  in  which  excision  of  por- 
tions of  the  cerebral  cortex  was  performed  upon  the  insane ;  it 
would  appear  that  some  improvement  was  thus  obtained  in  the 
quieting  of  excitement  and  in  the  suppression  of  hallucinations. 

"  Tuke  discusses  the  surgical  treatment  of  intra-cranial  fluid- 
pressure,  which  he  thinks  is  not  awarded  its  true  value.  He  gives 
two  instances  of  '  general  paralysis  of  the  insane,'  one  of  his  own 
and  one  of  Claye  Shaw's,  in  which  trephining  was  followed  by 
marked  improvement,  and  suggests  that  there  may  be  other  cases, 
characterized  by  coma,  delirium,  and  acute  mania,  produced  by  a 
congested  and  dropsical  condition  of  the  brain,  or  by  meningitis, 
in  which  an  opening  into  the  dura  would  be  of  advantage.  He 
thinks  that  the  importance  of  the  lymphatic  system  of  the  en- 
cephalon,  as  a  factor  in  morbid  processes,  has  been  too  much 
overlooked. 

"  In  Shaw's  case  there  was  a  history  of  severe  injury  above  the 
left  ear  fifteen  months  previously.  After  trephining,  the  patient, 
a  man  aged  twenty-nine,  improved  in  many  respects,  mentally  as 
well  as  physically,  but  six  months  later  he  died  after  prolonged 
coma  preceded  by  strong  convulsions.  Cripps,  who  was  the 
operator  in  this  case,  states  that  the  treatment  was  adopted  with 
the  view  of  relieving  undue  pressure  on  the  brain  caused  by  excess 
of  fluid  within  the  cranium. 

"Rivington  has  opposed  the  views  of  Tuke  and  Shaw  on 
pathological  and  mechanical  grounds.  He  does  not  think  that 
there  is  warrant  for  expectation  of  benefit  from  operative  inter- 
ference in  cases  of  general  paralysis  of  the  insane. 

"  In  another  case  of  general  paresis  trephining  is  reported  by 
AVagner  to  have  produced  marked  improvement.     But  it  seems 


324  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

likely  that  in  this  instance,  as  in  some,  at  least,  of  those  published 
heretofore,  there  were  pressure-symptoms  superadded  to  those  of 
general  paresis ;  these  being  relieved  by  operation,  there  was,  inci- 
dentally, an  improvement  in  the  patient's  main  disorder.  One 
can  hardly  believe  that  it  will  be  found  possible  to  remedy  a  con- 
dition of  degeneration,  such  as  exists  in  the  general  paralysis  of 
the  insane,  by  any  surgical  procedure."  * 

"This  subject  is  discussed  by  Percy  Smith,  and  attention  is 
called  to  the  fact  that  it  is  not  uncommon  for  long  periods  of 
remission,  or  for  real  or  supposed  recovery,  to  be  observed  in 
cases  of  general  paresis.  Further,  he  quotes  from  Mickle  the 
statement  that  several  instances  of  recovery  or  of  very  prolonged 
remission  have  supervened  on  accidents,  violent  injuries,  or  dis- 
eases of  such  a  kind  as  to  produce  so-called  ^  revulsive  effects.'  "  f 

*  Packard,  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 
•j-  Annual  of  the  Universal  Medical  Sciences,  Sajous,  1891. 


LECTUKE  XIX. 

DIAGNOSIS   OF   INSANITY   IN   GENERAL. 

Diagnosis  of  Insanity  in  General — Cautions  necessary  in  Determining  Insanity — Simu- 
lated Insanity — Tests — Simulation  of  Insanity  by  the  Insane — Prognosis  of  Insanity 
— Pathology  and  Anatomical  Appearances  of  Insanity — The  Frontal  Lobes  are  the 
Seat  of  Intellect — Lesions  of  Frontal  Lobes  produce  Changes  of  Character — Re- 
capitulation— Brain-Surgery  in  Insanity — Comparative  Advantages  of  Home  and 
Asylum  Treatment. 

Gentlemen, — A  few  brief  remarks  in  regard  to  the  diagnosis 
of  insanity  will  now  be  appropriate.  Is  there  any  other  affection 
with  which  it  may  be  confounded  ?  Is  it  not  possible  to  make  a 
mistake  ?  I  believe  that,  when  fully  developed,  it  can  be  easily 
recognized  with  ordinary  care  and  scrutiny.  The  difficulty  is  far 
greater  when  insanity  is  only  suspected,  especially  when  you  are 
called  upon  as  expert  witnesses  in  a  court  of  law.  Some  diseases 
might  be  confounded  with  it.  Acute  meningitis  with  acute 
delirium  has  been  mistaken  for  acute  mania;  but  in  the  latter 
disease  there  is  no  elevation  of  temperature,  which  is  a  marked 
feature  of  the  former ;  febrile  phenomena  exist  in  all  inflammatory 
affections,  and  are  therefore  present  in  meningeal  disorders.  There 
is,  it  is  true,  an  elevation  of  temperature  in  one  form  of  insanity, 
already  described,  but  only  in  one, — acute  delirious  mania. 

Delirium  tremens  presents  some  of  the  features  of  insanity 
which  are  manifested  when  a  person  has  been  habitually  addicted 
to  alcoholic  excesses  and  prolonged  debauches.  In  ordinary  cases 
of  delirium  tremens  it  is  hardly  possible  to  make  a  mistake ;  be- 
cause, as  you  will  learn  more  particularly  when  we  study  that 
disease,  there  always  exists  a  peculiar  loquacity,  a  remarkable, 
good-natured  delirium,  with  visual  hallucinations,  enabling  a 
physician  of  only  slight  experience  to  make  the  distinction.  The 
tremor  also  is  peculiar,  produced,  as  it  is,  by  the  action  of  the 
alcohol  upon  the  motor  nervous  system.  But  a  man  may  be 
deeply  under  alcoholic  influence  and  extremely  excited,  perhaps 

325 


326  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

showing  strong  homicidal  or  suicidal  tendencies,  while  the  physi- 
cian may  be  unable  to  say  whether  he  is  laboring  under  acute 
mania  or  alcoholism.  The  diagnosis  at  times  may  be  quite  diffi- 
cult ;  but  we  have  one  fact  that  may  help  us  in  such  cases,  which 
is,  that  in  ordinary  alcoholism  the  patient  is  much  better  after  good 
and  refreshing  sleep.  If,  therefore,  after  having  obtained  the  de- 
sired rest,  the  patient  awakes  as  wild  and  violent  as  he  was  on 
the  day  previous,  or  even  more  so,  the  probabilities  are  that  it  is 
a  case  of  acute  mania  instead  of  delirium  tremens.  Besides  this, 
the  absence  of  the  ordinary  symptoms  of  alcoholism — namely, 
the  clammy  perspiration,  the  characteristic  visual  hallucinations, 
the  rapid,  frequent  pulse,  and  the  tremor — readily  removes  many 
of  the  difficulties  attending  the  diagnosis. 

To  distinguish  some  particular  forms  of  insanity,  and  to  deter- 
mine the  fact  of  a  man's  being  sane  or  insane,  are  wholly  different 
questions,  which  are  apt  to  prove  very  vexatious.  Should  you 
declare  a  sane  person  to  be  a  lunatic,  and  send  him  to  an  asylum, 
thereby  unjustly  depriving  him  of  his  liberty,  you  may  expect  that, 
if  he  gets  out  and  proves  the  error  of  your  diagnosis,  he  will  cause 
you  much  trouble,  especially  if  you  possess  any  property  which 
would  justify  him  in  instituting  civil  proceedings  against  you.  Now, 
how  are  you  to  determine  these  matters  with  safety,  as  there  is  so 
much  difference  between  the  cases  we  meet  ?  One  general  rule  I 
can  give  you  in  this  regard ;  which  is,  always  to  avoid  rash  and 
hasty  action  :  never  to  hurry  your  decision,  but  to  study  the  his- 
tory of  the  patient,  his  idiosyncrasies,  and  in  particular  any  change 
in  his  character, — an  important  matter,  to  which  I  have  frequently 
adverted  throughout  my  lectures  upon  insanity.  This  departure 
from  one's  normal  self  is  manifested  by  certain  actions  or  feelings 
which  never  before  existed.  Be  cautious,  and  do  not  blindly 
accept  the  statements  of  relatives,  as  they  may  be  biassed  by  a 
desire  to  remove  the  person  out  of  their  way.  You  cannot  be  too 
prudent ;  and  you  should  always  give  the  patient  the  benefit  of  the 
doubt.  Never  blindly  assume  responsibilities  :  if  the  patient  be 
really  insane,  he  will  sooner  or  later  show  it.  If  you  have  care- 
fully followed  me  in  these  lectures,  you  -will  know  that,  although  a 
man  may  suffer  from  derangement  of  the  affective  type  with  very 
little  evidence  of  accompanying  ideational  insanity, — speaking 
quite  coherently  and  rationally, — he,  nevertheless,  cannot  control 


DIAGNOSIS   OF   INSANITY   IN   GENERAL.  327 

his  actions ;  and,  as  this  affective  form  underlies  all  others,  his 
actions  at  some  time  or  other  are  sure  to  reveal  his  insanity.  If 
this  be  the  case,  the  patient  must,  of  course,  be  isolated  in  an 
asylum,  as  he  is  out  of  harmony  with  his  social  sphere,  and  must 
be  sequestered  to  prevent  him  from  exercising  a  pernicious  in- 
fluence on  the  individuals  composing  the  society  of  which  he  is  an 
element.  I  repeat  it,  be  very  cautious  and  prudent,  before  giving 
an  opinion  in  the  affirmative  and  participating  in  the  subsequent 
proceedings ;  for,  if  you  do  not,  you  may  bring  upon  yourselves 
an  immense  amount  of  trouble. 

I  shall  not  dwell  long  upon  the  differential  diagnosis  between 
mania,  melancholia,  and  the  other  forms  of  insanity.  I  only  wish 
once  more  to  impress  upon  your  minds  that  all  insane  persons 
do  not  necessarily  manifest  their  insanity  as  plainly  as  the  laity 
generally  imagine,  and  that  even  experts,  after  numerous  conver- 
sations, may  be  misled,  if  not  upon  their  guard.  If  experts  have 
to  exercise  care,  how  much  more  does  it  behoove  the  general  prac- 
titioner to  avoid  all  possible  sources  of  fallacy  !  If  you  remember 
this,  you  may  yet  thank  me  for  the  stress  I  lay  upon  these  facts, 
whose  appreciation  may  save  many  a  physician  from  most  per- 
plexing annoyances. 

If,  as  sometimes  happens,  a  delusion  exists,  and  the  patient 
endeavors  to  deceive  you,  it  may  require  many  visits  before  you 
can  arrive  at  a  knowledge  of  the  true  nature  of  the  case,  and  in 
matters  of  this  kind  you  should  never  allow  yourself  to  be  in- 
fluenced by  the  desire  of  friends  so  as  thereby  to  be  placed  in  a 
false  position.  I  have  already  told  you  of  a  case  in  which  an 
individual  so  carefully  concealed  his  insanity  that,  after  having 
him  under  my  care  for  two  years,  I  felt  convinced  of  his  sanity, 
and  consequently  wrote  to  his  brother  to  come  and  take  him 
home  ;  yet  on  the  very  night  of  the  brother's  arrival  the  patient 
became  so  violent  and  aggressive  as  to  necessitate  his  immediate 
restraint.  Of  course  such  people  are  harmless  in  an  asylum ; 
but  where  they  are  at  large,  homicidal  tendencies  very  frequently 
manifest  themselves,  as  well  as  other  dangerous  propensities. 

A  word  concerning  assumed  insanity.  You  may  be  called  ujjon 
to  give  your  opinion  in  a  trial  where  a  man  affects  insanity  in 
order  to  evade  punishment.  You  may  not  have  the  opportunity 
of  calling  in  experts,  and  the  criminal  will  endeavor  to  deceive 


328  DISEASES    OF    THE   NERVOUS   SYSTEM. 

you ;  therefore  you  must  be  on  your  guard.  Recollect  that  uo 
man  can  for  any  great  length  of  time  act  the  part  of  a  maniac. 
He  cannot  feign  insomnia ;  for  if  you  watch  him  closely  you 
will  find  that  in  moments  of  exhaustion  he  will  sleep  soundly 
without  the  use  of  an  anodyne.  Sometimes  such  people  pur- 
posely refuse  medication.  If  you  have  ever  seen  such  cases,  you 
will  readily  recognize  the  fact  that  pretended  maniacs  invariably 
overact  their  parts. 

In  commenting  upon  legitimate  devices  for  exposing  the  simu- 
lation of  insanity,  Spitzka  makes  the  following  observations : 
"  When  examining  the  patient,  let  the  interlocutor  remark  in  an 
undertone  to  a  by-stander  that  if  such  and  such  a  sign  were  pres- 
ent he  would  know  in  which  ward  to  put  him,  or  under  which 
form  of  insanity  to  classify  the  subject.  This  is  far  safer  than  the 
suggestion  adopted  from  the  French  writers  by  Ray,  and  copied 
from  him  by  some  recent  pamjjhleteers,  of  saying  that  if  such  and 
such  a  sign  were  present  the  interlocutor  would  believe  the  man 
to  be  insane.  This  would  put  a  cunning  simulator  on  his  guard. 
The  writer  had  to  deal  with  such  a  one  in  the  case  of  a  child- 
abductor  who  had  feigned  insanity  in  a  jail  once  before.  Suspect- 
ing that  the  recommendation  of  the  older  writers  would  have 
failed,  the  writer  turned  to  a  by-stander  and  said, '  This  is  a  most 
interesting  case,  and  I  have  frequently  remarked  that  these  patients 
do  not  remember  what  city  they  are  from.'  The  criminal  had 
previously  assigned  Baltimore  as  his  home,  and  this  was,  according 
to  the  legal  papers  in  the  case,  correct ;  but  on  being  interrogated 
he  said,  in  a  hesitating  and  whining  voice  altogether  unnatural  to 
a  person  suffering  from  monomania  with  sexual  perversion  (the 
form  claimed  to  exist),  '  Concord,  Cincinnati.'  " 

Dr.  C.  H.  Hughes,  of  St.  Louis,  has  written  an  excellent  article 
upon  "  Simulation  of  Insanity  by  the  Insane,"  proving  that  "  the 
insane  appear  at  times,  when  they  have  an  object  to  accomplish, 
more  crazy  than  and  different  from  what  they  really  are ;  this  is 
the  sense  in  which  we  use  the  term  simulation,  and  this  condition 
is  akin  to  that  of  feigning  by  the  sane.  Simulation,  while  it  pre- 
supposes a  degree  of  sanit^^,  does  not  require  that  the  patients 
should  be  wholly  sound  in  mind,  and  it  might  be  attempted  by 
a  convalescent  patient  not  thoroughly  recovered,  or  desirous  of 
remaining  longer  in  the  hospital,  or  for  some  other  cause." 


DIAGNOSIS   OF   INSANITY   IN   GENERAL.  329 

In  melancholia,  which  is  a  deep  derangement  of  the  affective 
type,  we  know  that,  in  consequence  of  a  disinclination  to  take 
food,  the  patient  will  resist  its  administration.  If  chronic  mania 
should  be  simulated,  you  might  be  easily  misled.  But  there  is  one 
peculiarity  in  all  these  simulations  of  insanity,  which  the  books 
refer  to,  that  those  who  attempt  the  deception  always  appear  to  be 
devoid  of  memory.  They  invariably  fail  to  have  any  recollection 
or  appreciation  of  time,  locality,  or  condition.  These  are  symp- 
toms more  characteristic  of  softening  of  the  brain  than  of  insanity. 
I  have  already  told  you,  in  speaking  of  partial  cerebral  anaemia, 
that  there  is  a  loss  of  memory,  which  becomes  more  apparent  as 
the  disease  progresses.  In  insanity,  on  the  other  hand,  the  most 
remarkable  memory  is  often  manifested,  except  in  dementia,  which, 
of  course,  is  readily  recognized  by  the  expression,  or,  more  cor- 
rectly, the  want  of  expression,  of  the  face,  and  by  the  almost  total 
abolition  of  the  mental  faculties,  with  a  previous  history  of  some 
acute  form  of  insanity.  But  in  feigning,  these  people  will  often 
affect  to  forget  that  they  saw  you  the  day  before,  or  fail  to  recollect 
their  own  names,  or  those  even  of  their  nearest  relatives,  etc.  We 
know  the  absurdity  of  such  assumptions,  a  knowledge  of  incal- 
culable benefit  to  the  diagnostician.  Recollect  also  one  other 
important  fact  in  this  connection.  In  some  persons  insanity  is 
easily  recognizable,  while  in  others  it  is  not  so,  nay,  it  may  be 
almost  impossible  to  affirm  its  presence, — even  to  such  an  extent 
that  experts  will  be  unsuccessful.  I  recall  the  case  of  a  man 
who  was  confined  in  St.  Vincent's  Asylum  by  an  order  of  the 
judge  of  the  criminal  court,  so  that  through  careful  observation 
I  might  be  enabled  to  determine  the  presence  or  absence  of  in- 
sanity. After  studying  his  case  for  three  months  I  was  unable  to 
decide,  when  he  was  sent  back  to  jail  and  subsequently  admitted 
simulation. 

The  prognosis  can  be  summed  up  in  a  few  words.  Insanity  is 
curable  in  direct  ratio  with  its  duration.  If  acute,  it  is  often 
amenable  to  treatment ;  but  not  so  if  chronic.  Therefore,  when 
of  less  than  three  months'  duration,  it  may  (in  at  least  seventy  per 
cent,  of  cases)  be  easily  conquered  by  therapeutic  measures ;  but 
when  it  passes  this  limit  a  cure  becomes  more  difficult  as  its 
duration  is  greater.  Again,  in  patients  not  over  thirty  years  of 
age,  insanity  is  quite  manageable,  but  in  old  people  the  prognosis 


330  DISEASES   OF  THE   NERVOUS   SYSTEM. 

is  very  unfavorable.  Where  the  insane  temperament  exists^  or 
where  insanit}-  has  existed  in  the  family,  there  is  less  hope  of 
permanent  cure.  Some  of  these  cases  may  recover,  but  in  those 
who  are  the  \dctims  of  an  innate  vice  of  constitution  or  of  an 
unstable  ners^ous  organization  a  relapse  may  be  confidently  pre- 
dicted. Such  individuals  remain  always  liable  to  outbursts  of 
insanity,  and  to  have  repeated  attacks.  If  you  know  the  histories 
of  cases  in  asylums,  you  may  easily  predict  that  certain  persons 
will  soon  return  when  you  discharge  them  after  apparent  cure. 
The  relapse  may  be  postponed,  but  you  may  rest  assured  that 
it  will  occur  sooner  or  later. 

PATHOLOGY  AXD  ANATOMICAL  APPEAEANCES. 

I  will  now  make  a  few  general  remarks  in  regard  to  the  pathol- 
ogy of  insanity.  In  my  lectures  upon  its  different  forms  I  have 
so  frequently  referred  to  its  underlying  pathology  that  there  is  but 
little  left  to  add.  I  have  already  told  you  that  insanity  is  a  dis- 
ease of  the  brain,  having  its  seat  in  definite  parts  of  that  organ, — 
in  the  cortical  portions  of  the  convolutions  of  the  cerebral  hemi- 
spheres,— though  its  initiatory  cause  may  not  exist  there,  but  may 
have  a  remote  seat,  as  the  bladder,  uterus,  lungs,  heart,  or  some 
other  organ.  But  the  proximate  seat,  the  anatomical  site  of  insan- 
ity, is  always  the  brain.  If  this  be  so,  do  you  expect  always  to 
find  manifest  changes  in  the  brain  after  death  from  insanity  ?  No  ] 
for,  though  it  may  have  been  caused  by  reflex  irritation,  as  from 
the  uterus,  for  instance,  propagated  to  the  brain,  still,  anatomical 
change  may  not  be  apparent  either  to  the  unassisted  eye  or  even 
to  the  higher  powers  of  the  microscope.  The  fact,  nevertheless, 
that  we  cannot  ascertain  such  changes  is  surely  no  proof  that 
they  do  not  exist.  Consider  now  that  we  are  dealing  here  with 
anatomical  elements  of  wonderful  subtlety, — with  a  labyrinth  of 
untrodden  intricacy, — indeed,  with  the  parts  which  evolve  and 
elaborate  thought  itself.  We  have  no  appliances  sufficiently 
subtle  to  detect  all  the  molecular  changes  which  may  have  oc- 
curred in  this  most  delicate  of  organized  structures, — the  brain. 
It  may  be  diseased,  and  its  disease  still  escape  the  scrutiny  of 
our  methods  of  investigation.  In  order  that  morbid  intellectual 
phenomena  may  be  produced,  we  must  presuppose  an  alteration 
in  the  physiological  condition  of  the  cortical  cells  of  the  cerebral 


DIAGNOSIS   OF   INSANITY   IN   GENERAL.  331 

convolutions,  or  at  least  in  those  that  preside  over  the  elaboration 
of  mental  phenomena. 

"  Welt,  as  the  result  of  careful  studies  upon  eight  cases  of  injury 
or  disease  of  the  frontal  lobes,  under  his  personal  observation,  in 
all  of  which  autopsies  were  made,  concludes  that  such  changes  in 
character  and  disposition  as  very  frequently  occur  after  lesions  of 
the  anterior  lobe,  directly  result  from  such  injuries  or  diseases. 
These  alterations  of  character  and  disposition  are  frequently  the 
only  symptoms,  no  motor  or  sensory  disturbances  being  evident. 
In  all  of  the  eight  autopsies,  the  convex  cortical  surface  of  the 
frontal  lobe  was  the  portion  affected.  In  three  of  these  cases  the 
lesion  involved  the  first  convolution  alone,  in  three  others  the  first 
and  third  were  involved,  and  in  two  the  lesion  extended  from  the 
first  to  the  third  and  included  the  second.  These  results,  together 
with  facts  accumulated  from  an  analysis  of  autopsies  in  a  large 
number  of  similar  cases  reported  by  others,  showed  that  the 
region  most  uniformly  affected  was  that  nearest  the  median  line 
or  the  first  frontal,  and  of  the  right  rather  than  the  left.  The 
mental  changes  vary  greatly  as  to  the  time  of  onset,  nature,  and 
duration.  It  will  be  seen  that  these  conclusions  are  in  accord  with 
Ferrier's  experiments  upon  this  region  in  monkeys,  and  those  of 
Goltz  upon  dogs,  and  of  Luciani  upon  pigeons  and  dogs.  In 
another  part  of  the  Annual  will  be  found  a  synopsis  of  three  cases 
reported  by  Thompson,  of  tumors  located  in  the  frontal  region, 
having  an  important  bearing  upon  the  functions  of  this  portion 
of  the  brain. 

"  A  typical  example  of  the  physical  and  mental  effects  of  injury 
to  the  fore  brain  is  furnished  in  the  history  of  an  inmate  of  the 
Zurich  Hospital.  The  man,  while  drunk,  fell  one  hundred  feet, 
suffering  a  splinter  fracture  of  both  frontal  bones,  with  contusion 
and  efflux  of  brain-substance  from  the  frontal  reo^ions.  The 
man,  who  had  before  been  peaceable,  good-natured,  cheerful,  and 
cleanly,  became  malicious,  slanderous,  violently  quarrelsome,  and 
dirty.     No  other  morbid  changes  were  manifested."  * 

The  late  Dr.  Gray,  of  the  Utica  Asylum,  one  of  the  most  gifted 
and  distinguished  of  American  alienists,  has  greatly  contributed  to 


*  Landon  Carter  Gray,  Annual  of  the  Universal  Medical  Sciences,  Sajons, 
1891. 


332  DISEASES   OF   THE   NERVOUS   SYSTEM. 

our  knowledge  of  insanity,  and  has  illustrated  his  contributions  to 
cerebral  pathology  by  means  of  beautiful  micro-photographs.  His 
conclusions,  to  quote  his  own  words,  are,  "  Although  the  cases  thus 
far  examined  may  be  regarded  insufficient  to  establish  general 
conclusions,  they  go  to  strengthen  the  conviction  sustained  by  the 
laws  of  general  pathology,  that  insanity  is  a  physical  disease  of 
the  brain,  and  that  the  mental  phenomena  are  symptoms  ;  further, 
that  the  microscope,  with  patient  and  close  investigation,  will 
continue  to  disclose  structural  changes  in  the  cerebral  tissue  as 
marked  as  those  heretofore  unsuspected  when  examinations  were 
limited  to  the  scalpel  and  naked  eye ;  and  in  tliese  investiga- 
tions, when  the  entire  range  of  the  disease,  in  every  stage  of  its 
progress,  shall  have  been  brought  under  the  microscope,  we  may 
be  able  to  solve  tlie  problem  of  the  morbid  processes  conveniently 
denominated  insanity. 

"  Another  conclusion  to  which  these  investigations  must  natu- 
rally lead  is,  that  the  variety  and  changes  in  the  predominant 
symptoms  of  insanity  may  find  their  explanation  not  so  much  in 
the  variety  of  lesions  as  in  the  special  parts  of  the  cerebral  centres 
which  are  morbidly  involved  in  each  case ;  or,  to  bring  the  idea 
within  narrower  limits,  that  ideational,  emotional,  and  motor 
disturbances  have  their  foundation  in  the  extent  and  degree  to 
which  the  nerve-elements  that  minister  to  the  execution  of  the 
intellectual  and  motor  acts  are  involved  in  the  lesion.  When  the 
disease  reaches  its  ultimate  stage,  all  distinctions  cease,  dementia 
being  the  same  closing  stage  of  every  so-called  form  of  insanity." 
In  the  Thirty-Second  Annual  Report  of  the  State  Lunatic  Asylum, 
Dr.  Gray  remarks,  "  Continued  experience  not  only  confirms  the 
truth  of  this  position,  but  also  that,  in  all  cases,  post-mortem  ex- 
amination will  reveal  organic  lesions,  changes  in  the  condition  of 
the  vessels  or  structures  of  the  brain  or  its  membranes."  He  dis- 
cards the  term  functional  disease  as  a  "  phantom  of  the  mind,"  as 
it  has  been  designated  by  Winslow.* 

According  to  the  older  humoral  or  vascular  theory,  all  forms  of 
insanity  were  considered  as  the  result  of  congestion  of  some  part 
of  the  brain.  But  just  as  in  inflammation  there  is  always  a 
primary  tissue-irritation,  which  is  extra-vascular,  or,  I  may  say, 

*  American  Journal  of  Insanity,  July,  1875. 


DIAGNOSIS   OF  INSANITY   IN   GENERAL.  333 

interstitial,  so  insanity  originates  from  disturbances,  whether  pri- 
marily interstitial  or  parenchymatous,  in  the  ultimate  nervous 
constituents  outside  of  the  vessels,  the  primary  changes  not  being 
due  to  an  increased  flow  of  blood.  I  care  not  what  doctrine  of  in- 
flammation you  have  learned,  I  hold  that  since  the  views  of  Vir- 
chow  have  been  promulgated  it  must  be  held  as  established  that 
in  inflammation  there  is  an  irritation  of  the  cells  composing  the 
tissue  outside  of  the  vessels.  Exactly  the  same  law  holds  good 
in  insanity,  although  itself  not  originally  an  inflammatory  dis- 
ease, for  Dr.  Gray  has  proved  that  increased  connective-tissue 
proliferation  plays  an  important  part  as  one  of  its  primary  factors. 
It  is  true  that  insanity  may  be  induced  by  some  adynamic  states 
of  the  system,  through  influences  of  the  blood  on  the  cells  and 
ultimate  constituents  of  the  cerebral  nervous  texture ;  but  prone- 
ness  to  this  disease  does  not  reside  in  the  blood  itself,  but  is 
founded  in  a  peculiar  instability  of  the  cerebral  cells,  composing 
as  they  do  the  material  structure  of  the  temple  in  which  the  mind 
resides.  Whenever  perturbing  influences  are  experienced  by  the 
material  fabric  (the  bricks  and  mortar  of  which  the  temple  is 
composed),  disturbances  of  the  normal  evolution  of  mental  phe- 
nomena will  necessarily  occur,  improper  ideation  will  ensue,  and 
insanity  be  developed.  Therefore  the  starting-point  of  all  forms 
of  insanity  is  in  the  fundamental  constituent  elements  or  cells 
of  the  cortical  substance  of  the  hemispheres  of  the  brain.  Here 
the  disease  starts  ah  initio.  Hence  you  readily  see  that  it  is  the 
constituent  elements  of  the  cells  which  are  at  fault  in  insanity. 
These  cells  may  have  their  own  laws  of  elaboration  and  evolu- 
tion, of  which  we  know  nothing,  and  which  science  may  perhaps 
never  reveal.  But  how  is  it  with  other  cells  ?  Do  we  exactly 
know  the  working  of  any  of  them  ?  Though  insanity  proba- 
bly starts  in  the  cerebral  cells,  it  may  not  be  at  all  improbable 
that  there  are  consequent  though  undetectable  changes  in  every 
other  cell  in  the  body,  so  that  an  insane  person  may  be  insane  to 
the  very  tips  of  his  fingers.  This  is  surely  no  more  difficult  to 
understand  than  the  fact  that  the  renal  or  hepatic  cells  never  fail 
to  select  those  constituents  of  the  blood  which  are  adapted  to  the 
elaboration  of  their  proper  secretions.  Can  we  explain  how  ali- 
ments are  changed  into  flesh  ?  We  know  that  they  are  so  changed, 
and  accept  the  undeniable  fact  of  daily  transubstantiation  during 


334  DISEASES   OF   THE   NERVOUS  SYSTEM. 

digestion  ;  but  can  we  understand  all  the  special  transformations 
v\'liicli  occur  in  these  processes  of  assimilation  ?  Or  can  we  ac- 
count for  cell-impregnation  ?  Why  is  it  that  when  a  woman  has 
children  by  a  second  husband  they  may  bear  a  very  remarkable 
resemblance  to  the  first,  though  he  may  have  been  dead  for  years  ? 
We  know  that  it  is  so,  and  might  oifer  an  explanation  by  saying 
that  the  cells  had  been  perfused  with  a  certain  psychical  influ- 
ence lasting  for  a  lifetime  ;  but  such  an  explanation  would  be  at 
best  hypothetical. 

But  though  some  of  the  pathological  conditions  of  insanity  are 
very  obscure,  there  are  others  that  we  can  more  readily  understand. 
For  instance,  to  have  a  healthy  mind,  one  must  have  a  healthy 
body.  If  the  body  be  pervaded  with  poisoned  blood,  whether  by 
the  eflfects  of  syphilis,  of  typhoid  fever,  or  of  variola,  etc.,  it  is 
evident  that  the  functions  of  the  brain  will  be  more  or  less  at 
fault,  because  for  the  healthy  evolution  of  cerebral  phenomena 
healthy  blood — normal,  both  quantitatively  and  qualitatively — 
is  indispensable.  You  must  recollect  that  a  man  may  be  insane 
vrith  either  an  anaemic  or  a  hypersemic  condition  of  the  brain. 
Poisoned  blood  cannot  subserve  the  proper  action  of  the  ideational 
centres.  Healthy  blood  is  required  for  the  evolution  of  normal 
thought,  just  as  in  the  liver  pure  blood  is  requisite  for  the  produc- 
tion of  normal  bile.  You  may,  perhaps,  accuse  me  of  holding 
materialistic  views,  because  I  compare  the  psychical  evolution  to 
that  of  bile.  I  must  state,  however,  that  the  more  I  study  the 
phenomena  of  life  and  the  functions  of  our  organism,  especially 
those  of  the  brain,  with  its  wonderful  ramifications  through  the  sys- 
tem, its  ever- varying  and  almost  limitless  psychological  powers, 
its  delicate  mechanism,  and  the  mystery  of  its  functions,  the  more 
I  appreciate  the  difficulties  of  cerebral  physiology  and  psychology. 
The  brain  is  like  an  seolian  harp,  whose  strings  vibrating  to  the 
passing  wind  give  forth  euphonious  sounds.  The  mind  employs 
the  brain  for  the  production  of  thought.  The  mind  is  not  ma- 
terial ;  but  if  the  brain  be  not  in  a  physiological  condition,  it 
becomes  a  false  messenger,  an  untruthful  interpreter  of  external 
things,  and  its  play  is  inconsonant,  inharmonious,  discordant, 
and  what  we  call  insanity  appears.  That  the  brain  is  only  the 
physical  organ  of  the  mind  is  shown  by  the  fact  that  the  quantity 
of  the  phosphates  in  the  urine  varies  with  the  amount  of  mental 


DIAGNOSIS   OF   INSANITY   IN   GENERAL.  335 

labor  undergone ;  for  the  more  violent  the  action  of  the  mind, 
the  greater  is  the  destruction,  or  the  retrograde  metamorphosis, 
of  the  brain-tissue. 

So  much  for  the  manner  in  which  a  change  in  quantity  or 
quality  of  the  blood  may  produce  insanity.  A  few  points  still 
claim  our  consideration. 

We  have  reason  to  believe  that  insanity  originates  in  the  tissues 
outside  of  the  vessels  ;  it  may,  however,  be  influenced  by  vascular 
causes,  and  especially  by  reflex  action.  I  do  not  think  I  could 
give  a  more  practical  illustration  of  this  than  by  citing  a  case 
already  mentioned,  one  of  prolapsus  uteri  attended  by  melan- 
cholia, where  the  melancholia  disappeared  immediately  upon  the 
reduction  of  the  prolapsed  organ  and  its  restoration  to  its  nor- 
mal position  ;  but  as  soon  as  the  pessary  was  removed  and  the 
uterus  once  more  descended,  the  insanity  reappeared,  to  vanish 
again  upon  a  subsequent  reductiozi  of  the  prolapsus.  I  could  not 
give  you  a  plainer  illustration  of  the  effects  of  reflex  action.  It 
is  not  more  difficult  to  understand  than  that  dizziness  and  dila- 
tation of  the  pupil  are  often  symptomatic  of  taenia  and  disappear 
with  the  expulsion  of  the  parasite.  This  proves  the  necessity  of 
ascertaining  the  cause  of  the  reflex  action,  whether  it  be  thoracic, 
pelvic,  or  abdominal.  Direct  your  remedies  to  the  causative  con- 
dition, and  in  relieving  this  you  will  often  eradicate  the  insanity. 

It  is  quite  a  common  thing  to  find  insane  females  suffering  from 
metritis,  cervicitis,  etc. ;  and  the  cure  of  these  complications  has 
often  restored  them  to  reason.  I  recollect  a  case  where  all  previous 
treatment  had  failed,  in  which  after  the  cure  of  an  obstinate 
leucorrhoea  the  patient  showed  the  first  symptoms  of  improvement, 
the  insanity  finally  disappearing.  This  shows  the  connection  be- 
tween cause  and  effect ;  and  as  it  is  in  insanity,  so  it  is  sometimes 
in  paraplegia  caused  by  reflex  irritation  from  disease  of  the  genito- 
urinary organs,  which  is  occasionally  cured  by  removing  a  simple 
gonorrhoea.  If  such  an  affection  can  have  these  effects  upon  the 
spinal  cord,  how  subservient  to  the  influence  of  reflexive  irritation 
must  we  concede  the  brain  to  be, — this  great  centre,  this  metropolis 
of  the  body,  in  relation  with  every  muscle,  with  every  nerve  and 
fibre  of  our  system  ! 

"  Indeed,  nearly  every  pathological  condition  of  the  brain  known 
in  insanity,  in  kind,  if  not  in  extent  and  degree,  may  be  found  in 


336  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

diseased  or  injured  brains  where  there  has  been  no  mental  disease 
in  consequence.  .  .  . 

"  In  those  forms  of  mental  disease  where  changes  are  found, 
the  most  important  and  constant  are  in  the  cortex  of  the  brain, 
especially  in  the  fore,  upper,  and  middle  parts  of  the  periphery, 
involving  usually  also  the  membranes.  In  beginning  acute  mania 
the  condition  of  the  blood  affecting  the  brain  or  the  pathological 
changes  are  probably  as  nearly  identical  with  those  in  the  acute 
stage  of  pneumonia,  certain  forms  of  typhoid  fever,  cerebro-spinal 
meningitis,  and  other  diseases,  as  the  symptoms  of  the  mania  are 
now  and  then  difficult  to  differentiate  from  those  of  the  other 
diseases  just  mentioned.  In  rheumatism,  syphilis,  malarial  poi- 
soning, and  Bright's  disease,  with  mania,  we  find  no  distinctive 
pathological  conditions  to  account  for  the  maniacal  symptoms. 

"  If  asked  whether  there  is  a  fixed  lesion  of  the  brain  or  any 
of  its  parts  corresponding  to  given  psychological  changes,  we 
should  be  obliged  to  say  no,  except  in  the  cases  of  incurable 
dementia.  If  asked  whether  there  are  important  morbid  changes 
-corresponding  with  all  cases  of  insanity,  we  can  only  say  yes, 
sooner  or  later,  in  the  majority  of  cases,  and  that  there  are  certain 
destructive  lesions,  chiefly  inflammatory,  atrophic,  and  degenera- 
tive, which  invariably  mean  marked  deterioration  of  the  mind. 
As  regards  diseases  of  other  organs  than  the  brain,  the  insane,  like 
the  sane,  die  of  all  of  them,  and  in  especially  large  numbers  of 
pulmonary  consumption. 

"  Insanity  may,  both  in  its  acute  and  chronic  forms,  be  the 
result  or  symptom  of  simple  anomalous  excitation  or  nutrition  of 
the  brain  or  of  inhibition  of  some  of  its  portions,  without  any 
change  in  its  gross  appearances  which  can  be  detected  by  our 
present  methods  of  research.  In  the  majority  of  cases  there  are 
found  diseased  conditions  which  become  more  manifest  the  longer 
the  duration  of  the  disease,  aj)pearing  for  the  most  part  in  the 
blood-vessels,  pia  mater,  and  cortex  of  the  brain,  but  also  in  the 
medullary  jiortion,  many  of  which  are  recognized  only  in  their 
late  stasres.  In  the  functional  mental  diseases  there  is  no  char- 
acteristic  lesion  of  the  brain  as  yet  recognizable,  even  in  the  latest 
stages,  more  than  is  to  be  found  in  the  brains  of  persons  dying 
from  other  causes.  When  apparently  local  injuries  or  diseases 
cause  insanity,  they  probably  do  so  through  a  general  disturbance 


DIAGNOSIS   OF   INSANITY   IN   GENERAL.  337 

of  the  brain,  or  through  diffused  disease  resulting  therefrom,  and 
for  the  most  part  affecting  both  hemispheres.  The  molecular, 
chemical,  anatomical,  physiological,  pathological,  or  physical 
changes  in  the  brain  which  give  rise  to  insanity,  and  their  rela- 
tion to  the  grosser  pathological  conditions  of  the  brain,  are  still 
not  clearly  made  out."   ^(Folsom.) 

Before  dismissing  the  subject,  I  would  observe  that  whenever 
a  predisposition  to  insanity  exists,  it  may  be  induced  by  excessive 
functional  action  of  any  part,  notably  of  the  brain  itself.  Such 
excessive  functional  activity  will  produce  an  irritative  exhaustion, 
Avhose  continued  influence  will  result  in  emotional  disturbance ; 
this  being  reflected  to  the  brain,  insanity  follows.  Knowing 
the  laws  of  health,  we  should  never  forget  that  "  tired  nature's 
sweet  restorer,"  sleep,  which  permits  recuperation  of  the  forces 
and  prevents  incessant  wear  of  the  tissues,  is  the  great  prophy- 
lactic of  insanity  :  so  that  whenever  prolonged  loss  of  rest  exists, 
we  must  at  once  induce  profound  and  adequate  sleep. 

RECAPITULATION. 

Insanity  is  a  disease  which  has  always  its  seat,  though  not 
necessarily  its  cause,  in  the  brain.  It  is  manifested,  like  other 
maladies,  in  an  acute  and  a  chronic  form.  Its  origin,  I  repeat,  is 
not  invariably  in  the  brain,  for  in  consequence  of  the  close  sym- 
pathy which  exists  between  this  great  nervous  centre  and  all  the 
other  portions  of  the  body,  morbid  action  starting  in  any  part  of 
the  economy  may,  in  susceptible  individuals,  be  the  exciting  cause 
of  a  reflex  irritation  which  disturbs  the  functions  and  impairs 
the  delicate  mechanism  of  that  wonderful  organ  whence  all  intel- 
lectual manifestations  are  derived. 

Too  much  stress  cannot  be  laid  upon  the  fact  that  insanity  is 
curable  in  direct  ratio  with  its  duration.  Although  cases  of  many 
years'  continuance  are  sometimes  cured,  and  notwithstanding  the 
well-admitted  fact  that  no  case  is  necessarily  incurable,  yet  it  is 
practically  in  the  field  of  acute  cases  that  the  physician  may  expect 
to  reap  his  most  abundant  and  successful  harvests.  Many  authors 
place  the  limit  of  the  acute  stage  at  three  months  from  inception. 
The  farther  we  pass  beyond  the  third  month,  the  more  difiicult 
will  be  the  cure.  You  are  doubtless  aware  that  the  prognosti- 
cations of  ordinary  pulmonary  affections  are  favorable  just  in 

22 


338  DISEASES   OF   THE   NERVOUS  SYSTEM. 

proportion  to  their  recency  or  remoteness  of  origin.  Acute  in- 
flammation of  the  lungs,  with  our  modern  therapeutic  resources, 
is  not  often  a  fatal  disease.  Phthisis  pulmonalis  still  but  too 
frequently  baffles  our  best-directed  efforts  to  arrest  its  terrible 
ravages.  On  the  other  hand,  the  management  of  acute  mania  or 
melancholia  frequently  attests  the  brilliant  results  accomplished  by 
psychological  physicians,  while  monomania,  chronic  mania,  and 
dementia  are  still  the  opprobrium  of  our  art.  A  brain  which  is 
the  seat  of  dementia  is  comparable  to  a  battle-field,  where  all  was 
once  storm,  fury,  and  irresistible  violence ;  but  now,  wreck,  ruin, 
and  desolation.  For  these  unfortunate  victims  the  propitious 
moment  has  forever  passed,  because  they  did  not  reach  the  haven 
of  an  asylum  in  time  to  prevent  a  disaster  from  which  they  can 
never  recover.  This  irreparable  mischief  has  been  inflicted  upon 
them  in  consequence  of  the  procrastination  of  friends,  and  the 
defects  of  faulty  and  unphilosophical  legislation.  The  conclusion 
to  be  drawn  is  manifest, — all  patients  should  be  sent  to  an  asylum 
upon  the  very  first  development  of  mental  aberration  ;  the  success 
which  will  so  often  follow  such  a  course  will  soon  convince  you 
of  its  wisdom.  The  morbid  processes,  if  you  lose  valuable  time, 
make  sure  and  rapid  strides ;  every  day  that  you  allow  to  pass 
without  medical  treatment  tends  to  insure  the  terrible  doom  of 
chronic  insanity  which  impends  over  these  unfortunates. 

Emory  Lanphear,  of  Kansas  City,  Missouri,  in  a  late  article  in 
the  American  Journal  of  Surgery  and  Gynecology,  observes, — 

"  The  suggestion  to  open  the  skull  in  insanity  is  not  new,  but 
its  execution  is  recent.  Burckhardt  has  detailed  six  cases  of  in- 
sanity with  marked  hallucinations,  which  he  subjected  to  operative 
treatment.  '  In  two  cases  he  aimed  to  intersect  the  paths  of  as- 
sociation, which  he  thinks  transmits  the  pathological  impression 
coming  from  sensory  parts  and  certain  ideogenic  areas  of  the 
brain ;  a  portion  of  the  frontal  and  parietal  lobes,  before  and  be- 
hind the  ascending  convolutions,  were  removed  with  very  satis- 
factory results  in  one  case,  the  other  being  still  under  treatment. 
In  the  other  four  cases  the  hallucinations  were  more  or  less  acute, 
and  in  these  cases  the  operator  attacked  the  centres'  through  whose 
injury  sensory  and  motor  aphasia  are  produced,  and  removed  a 
part  of  the  first  temporal  and  third  frontal  on  the  left  side,  whicli 
appeared  diseased,  and  with  satisfactory  results.     It  is  possible 


DIAGNOSIS   OF   INSANITY   IN   GENERAL,.  339 

that,  with  additional  experience  and  a  minute  study  of  the  patho- 
logical changes  seen  in  the  brain,  the  knife  may  be  the  means  of 
restoring  to  reason  many  cases  now  considered  incurable.'  But 
the  question  naturally  arises,  were  or  were  not  these  cases  the 
result  of  the  operation  per  sef  Only  further  experimentation 
and  careful  observation  can  determine.  It  is  in  the  first  stage  of 
general  paresis  that  I  shall  look  for  beneficial  results,  for  here  we 
have  a  mental  disease  (so  called)  which  is  dependent  upon  gross 
lesions.  In  insanity  due  to  intra-cranial  growths  the  indications 
are  always  to  operate." 

COMPAEATIVE    ADVANTAGES    OF    HOME   AND   ASYLUM    TREAT- 
MENT. 

Since  the  publication  of  the  first  edition  of  these  lectures, 
Seguin,  in  his  "  American  Clinical  Lectures,"  has  expressed  views 
on  the  above  subject  almost  identical  with  those  which  I  am  about 
to  quote  from  the  recent  excellent  treatise  on  "  Familiar  Forms  of 
Nervous  Disease,"  of  M.  Allen  Starr.  I  need  hardly  add  that, 
after  an  experience  of  a  quarter  of  a  century  in  the  treatment  of 
insanity,  I  can  fully  corroborate  all  his  assertions. 

"  \Yhile  it  is  apparent  from  the  foregoing  that  I  believe  in  the 
early  removal  of  most  cases  of  insanity  from  the  environment  in 
which  the  psychosis  has  developed,  I  am  by  no  means  an  admirer 
of  asylums  in  general  as  now  conducted.  The  large  public  insti- 
tutions are  hampered  in  their  treatment  by  the  enormous  number 
of  patients  and  by  the  lack  of  a  corresponding  number  of  physi- 
cians and  attendants.  The  superintendent  is  seldom  a  thoroughly 
trained  alienist,  and  in  some  States  these  charities  of  the  people 
are  unfortunately  made  to  subserve  the  interest  of  the  great  political 
machine.  Patients  cannot  derive  that  benefit  which  they  shou-d 
from  the  medical  superintendent's  long  experience,  because  their 
individual  requirements  must  be  sacrificed  to  the  many  demands 
upon  his  time  in  the  general  management.  His  assistants  are  too 
few  and  too  preoccupied  with  their  clerical  and  office  duties  to 
carefully  individualize  and  treat  the  patients.  Finally,  there  are 
too  many  patients.  A  State  asylum  containing  but  two  hundred 
patients  has  but  an  indifferent  public  standing.  It  must  have  a 
thousand  or  two  thousand  patients  in  oi'der  to  satisfy  the  ambition 
of  the  community  and  of  the  managers.     Small  wonder,  then. 


340  DISEASES   OF   THE   NERVOUS   SYSTEM. 

that  the  actual  object  of  the  institution  should  so  often  be  lost  to 
sight ! 

"Untilj  therefore,  these  great  charities,  now  little  more  than 
warehouses  for  the  storage  of  articles  unnecessary  or  in  society's 
way,  conform  more  to  the  character  of  a  hospital,  with  its  modern 
equipment,  its  attending  physicians,  and  its  consulting  specialists, 
the  higher  classes  of  private  asylums  in  the  hands  of  men  who  are 
known  for  their  professional  attainments  and  probity  of  character 
will  always  be  more  desirable  as  places  for  the  reception  and 
treatment  of  such  insane  patients  as  are  so  fortunate  as  to  be  able 
to  enjoy  their  advantages. 

"  It  is  to  be  hoped,  however,  that  at  some  future  day  our  general 
hospitals  will  provide  special  wards  or  pavilions  for  this  particular 
class  of  cases,  so  that  in  every  city  one  or  several  places  will  be  at 
all  times  ready  to  receive  the  acute  insane  and  care  for  their  sick 
brains  in  the  highest  scientific  manner." 


INDEX. 


Abscesses,  pulmonary,  73. 

pyaemic,  73. 
Actions  of  the  insane,  224,  225. 
Acute  dropsy  of  the  brain,  111. 

post-epileptic  insanity,  Spitzkaon,  33. 
Affective  insanity,  223. 
Afferent  blood-vessels,  too  slight  resistant 
power  of,  as   a   cause  of  cerebral  con- 
gestion, 34. 
Agraphia,  67. 
Aitken  on  syphilis  in  hasmatoma  of  the 

dura  mater,  151. 
Alcohol  as  a  cause  of  cerebral  hyperaemia, 

37. 
Alcoholic  insanity,  277. 

chronic,  Folsom  on,  278. 
Allbutt  on  the  optic  nerves  in  drunkards, 

171. 
Anaemia,  cerebral,  general,  87. 
partial,  55. 
symptoms  of  depression  in,  66. 
of  excitation  in,  66. 
Anatomical  appearances  of  cerebral  hyper- 

jemia,  40. 
Aortic    tumors    causing   cerebral  hyper- 

Eemia  by  pressure,  34. 
Apoplexy,  as  a  definition,  76. 
intra-arachnoidean,  163. 
Arndt  on  insolation,  32. 
Atmospheric    pressure,    influence    of,   on 

sleep,  26. 
Atrophy  of  the  brain  as  a  cause  of  cere- 
bral hyperasmia,  37. 
Aural  surgery,  Macewen  on,  154. 
Auricular  arteries,  influence  of,  in  cerebral 

congestion,  23. 
Auzouy  on  larvated  epilepsy,  296. 

on  mental  or  cerebral  epilepsy,  296. 


Bacteriology  of  oerebro-spinal  meningitis, 
Landon  Carter  Gray  on,  133,  134, 


Baillarger  on  the  essential  element  of  in- 
sanity, 237. 
on  insanity,  197. 
Ball,  description  of  an  insane  man,  237. 

on  insanity,  197. 
Bastian    on    blood-pigment    in    cerebral 

hyperemia,  42. 
Bed-sores  as  sources  of  emboli,  73. 
Blandford  on  forced  feeding  of  the  insane, 
250. 
on  impulsive  insanity,  229. 
on  insanity,  197. 
on  moral  insanity,  228. 
on  suicidal  and  homicidal   propensi- 
ties, 225. 
Blood-pressure  of  the  cerebral  circulation, 

17. 
Boerhaave's  maxim,  109. 
Boileau's  views  on  insanity,  195,  196. 
Border-land  of  insanity,  201. 
Savage  on,  202. 
Brain  as  a  dual  organ,  78. 

inhibitory  action  of,  Brown-Slquard 

on,  172. 
necrosis,  causes  of,  in  embolism,  61. 
relation  of,  to  cerebro- spinal  liquid, 

24. 
surgery,  Senn  on,  145,  1S3. 
symptoms,  cause  of,  in  fever,  44. 
Bright's  disease  and  insanity.  Brush  on, 

279. 
Brown-Sgquard  on  the  inhibitory  action 
of  the  brain,  172, 
on  the  mechanism  of  production   of 
the  symptoms  of  brain-disease,  173. 
Brush  on  mania,  255, 
Bucknill  on  responsibility,  295. 
Bucknill  and  Tuke  on  "  protopathic  in- 
sanity,"  262. 


Cadaveric  congestions,  effects  of,  43. 
Canals,  perivascular,  12. 

341 


842 


INDEX. 


Capillary  conditions    in   cases  of  active 

hyperagmia,  41. 
Cerebellum,  explanation  of  symptoms  in 

disease  of,  84. 
Cerebral  activity,  conditions  of,  in  sleep, 
27. 
anaemia,  pathological  anatomy  of,  63. 
arteries,  expansibility  of,  24. 
circulation,  11. 

blood-pressure  of,  17. 
effects  of  disturbances  of,  69. 
Gowers  on,  13. 
variation  in  volume  of,  17. 
vascular  tension  of,  17. 
vertebral,  influence  of,  20. 
hyperaemia  as    influenced    by  vaso- 
motor nerves,  34. 
etiology  of,  33. 
extra-cranial  causes  of,  33. 
limitations  of,  43. 
mild  form,  symptoms  of,  45. 
nosology  of,  29. 
severe  form,  symptoms  of,  46. 
pathology,  Folsom  on,  335,  336. 
pressure,  dynamic,  17. 
pulse,  114. 
sinuses,  inflammation  and  thrombosis 

of,  143. 
softening  as  caused  by  embolism,  60. 
extent  of,  64. 
symptoms  of,  65. 
substance,  incompressibility  of,  16. 
veins,  compressibility  of,  24. 
Cerebro-spinal  fluid,  11. 

relations  of,  to  brain,  24. 
meningitis,  124. 

an  essential  fever,  124. 
anatomical   appearances   of, 

133. 
Da  Costa  on,  131. 
epidemic  prevalence  of,  127. 
fulminant  type,  symptoms  of, 

128. 
generalities  of,  130. 
malarial  fever  and,  125. 
marasmus  in,  129. 
necrsemia  in,  129. 
prognosis  of,  129. 
purpuric  type,  symptoms  of, 

128. 
reabsorbent  fever  in,  129. 
Bussell  Reynolds  on,  126. 


Cerebro-spinal    meningitis,  scarlet  fever 
and,  125. 
symptoms  of  mild  form,  127. 
treatment  of,  130. 
typhus  fever  and,  125. 
varieties  of,  126. 
Ziemssen  on,  128. 
Change  of  character  in  insanity,  194. 

without   any   external   ade- 
quate cause,  216. 
Charcot  on  purulent  collections  in  aracb- 

noidean  cavity,  107. 
Charcot's  recent  investigations  on  cerebral 

softening,  81. 
Chloroform,  action  of,  on  cerebral  circu- 
lation, 26. 
Chronic  basilar  meningitis,  174. 
cerebral  meningitis,  169. 
vertical  meningitis,  169. 
Circular  insanity,  246. 
Classification  of  insanity,  199. 
Clots  from  intestinal  ulcers,  73. 

in  peripheral  veins,  72. 
Clouston  on  insanity,  197. 
Coagulation  necrosis,  72. 
Cohnheim  on  cerebral  arteries,  74. 

on  terminal  arteries,  72. 
Coincident  embolisms,  79. 
Cold  as  a  cause  of  cerebral  hyperaemia,  34. 
Collateral  circulation  in  embolism,  60. 
in  man  and  animals,  61. 
in  thrombosis,  60. 
lavys  of  establishment  of,  60. 
hypersemia,  55,  56,  62. 
oedema  as  explanatory  of  obscure  brain 
symptoms,  83,  84. 
in  cerebral  embolism,  78. 
in  cerebral  hyperaemia,  41. 
Coma  in  cerebral  embolism,  77. 
Comparative  advantages  of  home  and  asy- 
lum treatment,  Seguin   and  Starr 
on,  339. 
relationship  in  vascularity  of  diflFerent 
portions  of  the  brain,  42. 
Congestion,  acute,  fluxionary,  33. 

not  always  a  cause  of  coma  and  sleep- 
iness, 28. 
Contraction  of  pupils  in  hematoma  of  the 
dura  mater,  Griesinger  on,  151. 
of  vessels,  influence  of,  on  sleep,  27. 
Corroborative  proofs  of  insanity,  221. 
Cranium,  deep  lymphatics  of,  11. 


INDEX. 


343 


Cruveilhier  on  intra-arachnoidean  hemor- 
rhage, 158, 

Cutaneous  eruptions,  propriety  of  treat- 
ment of,  141. 


Da   Costa   on    cerebro-spinal    meningitis, 
131. 
on  characteristic  eruption  of  cerebro- 
spinal meningitis,  132. 
on  chissification  of  meningitis,  99. 
on    complications    of    cerebro-spinal 

meningitis,  132. 
on   condition   of    blood    in    cerebro- 
spinal meningitis,  131. 
on  permanent  deafness  and  sequelae 

of  cerebro-spinal  meningitis,  131. 
on     rapid    pulse    in     cerebro-spinal 
meningitis,  132. 
De  Cazal  on  meningitis  following  facial 

erysipelas,  106. 
Decomposition,  effects  of,  on  sleep,  27. 
Deep  lymphatics  of  the  cranium,  11. 
Degree  of  accountability  of  different  per- 
sons, Folsom  on,  195. 
Delirious  mania,  acute,  251. 
Delirium  grave,  251. 
Delirium  of  inanition,  Clymer  on,  88. 
"  De  lunatico  inquirendo,"  190. 
Delusion  as  a  criterion  of  insanity,  224. 
Dementia,  263. 

Savage  on,  265. 
terminal  or  chronic,  264. 
Diagnosis  of  leptomeningitis,  104,  105. 
Dieokenhoff  on  the  cerebral  circulation,  21. 
Different  modes  of  dying,  "Watson  on,  104. 
Disturbances  of  cerebral  circulation  pro- 
duce a  variation  of  symptoms,  84. 
Division   of  insanity  into  two  principal 

groups,  221,  222. 
Divisions  of  effective  insanity,  227. 
Doctor's  province  not  to  punish  for  crime, 

Folsom  on,  195. 
Dorsal  decubitus,  effects  of,  42. 
Double  consciousness,  Hammond  on,  293. 
Duality  of  the  brain,  78. 
Dura  mater,  sinuses  of,  24. 
Durand-Fardel     on     general     meningeal 

hemorrhage,  167. 
Durham  on   cerebral   circulation    during 
sleep,  25. 
on  nutrition  of  brain  during  sleep,  72. 


E. 

Early  stages  of  general  paralysis,  Folsom 
on,  304. 
Striimpell  on,  305. 
Ears,  reddening  of,  in  cerebral  congestion, 

23. 
Echeverria  on  premeditation  in  epilepsy, 

297. 
Elam  on  cerebral  circulation,  16. 
Emboli,  capillary,  59. 
fatty,  71. 

fibrinous,  derived  from  thrombi,  70. 
non-specific,  73. 
specific,  infectious,  73. 
Embolic  process  in  septicsemic  inflamma- 
tions, Gowers  on,  181. 
Embolism  as  cause  of  cerebral  softening, 
60. 
cerebral,  diagnosis  of,  from  cerebral 
hemorrhage,  79. 
frequency  of,  76. 
principal  site  of,  76. 
symptoms  of,  77. 
coincident,  79. 
collateral  oedema  in,  78. 
coma  in,  77. 

differentiated  from  thrombosis,  80. 
relationship  of  heart-disease  to,  70. 
resulting  from  thrombosis,  59. 
Embolus  from  air  in  blood-clot,  58,  71. 
infectious,  62-76. 
migratory,  71. 
Emminghaus  on  mental  disturbances  in 

Basedow's  disease,  282. 
Emotion  as  cause  of  cerebral  hyperaemia, 

34. 
Emotional  insanity  and  its  medico-legal 
relations,  211. 
various    facts    which    prove    it, 
226. 
Encroachment  upon  posterior  cranial  fossa, 

symptoms  of,  85. 
Endo-arteritis  deformans,  58. 
Endosmosis,  12. 
Epileptic  delusions,  286,  291. 
dementia,  Esquirol  on,  301. 
insanity  and  its  medico-legal  relations, 
Esquirol  on,  286. 
Falret  on,  288. 
Friedreich  on,  285. 
Reynolds,  J.  Russell,  on,  287. 


344 


INDEX. 


Epileptic  insanity   and   its   medico-legal 
relations,  Spitzka  on,  284. 
Trousseau  on,  285-290. 
vertigo.  Van  der  Kolk  on,  300. 
"Epileptic  psychical  equivalent,"  Spitzka 

on,  301. 
Epistaxis,  influence  of,  in  cerebral   con- 
gestion, 22. 
Erichsen's  views  on  extra-dural   hemor- 
rhage, 167. 
Eshmann  on  the  cerebral  lymphatics,  12. 
Esq^uirol  on  moral  alienation,  224. 

on   the  plea  of    emotional   insanity, 
238, 
Etiology  of  cerebral  hypersemia,  33. 

of  insanit}',  203. 
Exciting  causes  of  insanity,  207. 
Exosmosis,  12. 

Expansibility  of  cerebral  arteries,  24. 
Extra-cranial   causes  of  cerebral  hyper- 


Ealx  cerebri,  function  of,  63,  79. 

Eat  embolus,  71. 

Fever  a  cause  of  cerebral  hyperaemia,  34. 

Fleming  on  melancholia  cured  by  pessary, 

209. 
Fluid,  cerebro-spinal,  11. 
Folic  a  deux,  276. 
circulaire,  246. 
communiquee,  276. 
induite,  276. 
Folsom  on  cases  of  insanity  involving  the 
question  of  responsibility  for  crime, 
191. 
on  effects  of  insanity  upon  the  respon- 
sibility of  the  individual,  220. 
on  free    agency  in    mental    disease, 

193. 
on  hysterical  insanity,  275. 
on  katatonia,  274. 

on  legal  conception  of  insanity,  192. 
on  moral  insanity,  267. 
on  morbid  anatomy  of  general  paral- 
ysis, 320. 
on  popular   conceptions  of  insanity, 

191. 
on   wills   and   contracts   in   eases  of 
alleged  insanity,  192. 
Forced  feeding  of  the  insane,  Blandford 
on,  250. 


Forneris  on  neck-expansion  during  sleep, 

19. 
Fox  on  chronic  cerebral  meningitis,  178. 
French  penal   code  in  pleas  of  insanity, 

235. 
Frontal  lobes,  331. 

lesions   of,   produce    changes  in 

character,  331. 
the  intellectual  lobes,  331. 
Welt  on,  331. 
Fundamental  state  of  all  forms  of  insanity, 

223. 
Funke  on  sleep,  27. 
Furor  epilepticus,  292. 
melancholicus,  243. 

G. 

Gastric  irritation  as  reflex  cause  of  cere- 
bral hypersemia,  36. 
Gehrung  on  repression  of  menstruation  in 

melancholia,  250. 
General  cerebral  anaemia,  87. 
diagnosis  of,  90. 
diet  in,  94. 
Jaccoud  on,  87. 
Niemeyer  on,  90. 
treatment  of,  93. 
paralysis  of  the  insane,  Bayle  on,  303. 
Blandford  on,  303. 
Calmeil  on,  303. 
Delaye  on,  303. 
Esquirol  on,  303. 
morbid  anatomy  of,  Mendel 

on,  319. 
pathology  and  morbid  anat- 
omy of,  319. 
prognosis  of,  319. 
surgical  interference  in,  322. 
treatment  of,  321. 
tremor  in,  Seguin  on,  310. 
Gerhardt  on  thrombosis  of  the  transverse 

sinus,  144. 
Goitre,   influence   of,    on   cerebral    circu- 
lation, 19. 
Gold  treatment  in  hysteria,  Niemeyer  on, 

276. 
Gosselin  on  vaginal  hsematoceles,  162. 
Gowers  on  cerebral  circulation,  13. 
on  cerebro-spinal  meningitis,  131. 
on  chronic  syphilitic  meningitis,  180. 
on  differential  diagnosis  of  meningitis 
and  otitis,  182. 


INDEX. 


345 


Gowers  on  general  cerebral  anaemia,  89. 
on  "irritable  weakness,"  89. 
on  nosology  of  cerebral  hyperaemia, 

30. 
on  passive  cerebral  congestion,  41. 
on  strabismus  in  hysteria,  182. 
on  treatment  of  septic  meningitis,  179. 
on  trephining  in  pachymeningitis  ex- 
terna, 148. 
on  tubercles  of  the  choroid,  181. 
on  tubercular  meningitis,  117,  118. 
Gravity  of  symptoms  in  brain-disease  de- 
pends greatly  upon  site  of  lesion,  85. 
Gray,  G.  P.,  of  Utica,  on  cerebral  pathol- 
ogy, 331,  332. 
Gray,  Landon  Carter,  on  frontal  lobe,  331. 
on    post-cervical    pains     in    melan- 
cholia, 250. 
Griesinger  on  contraction  of  the  pupil  in 
hasmatoma  of  the  dura  mater,  55. 
on  "  herdsymptome,"  55. 
on  injuries  to  the  head,  298. 
on  insanity  during  pregnancy,  209. 
on  thrombosis  of  the  transverse  sinus, 
144. 
Gueniot  on  linear  craniotomy,  270. 
Guislain  on   insanity  during  pregnancy, 
209. 

H. 
Hsematocele,  peri-uterine,  Jardine  on,  162. 

vaginal,  Gosselin  on,  162. 
Heematoma,  159. 

of  the  dura  mater,  148. 
Aitken  on,  149. 
Gowers  on,  149. 
Griesinger  on,  149-150. 
Hewitt  on,  149. 
Huguenin  on,  149. 
Niemeyer  on,  157. 
symptoms  of,  151. 
syphilis  in,  Aitken  on,  151. 
treatment  of,  151. 
Hallucinations,  temporary  epileptic,  Ham- 
mond on,  300. 
Hammond  on  "  double  consciousness,"  293. 
on  faculties  of  the  mind,  294. 
on  "  irregular  or  abortive  paroxysms" 

of  epilepsy,  293. 
on      skin-eruptions       accompanying 

brain-diseases,  141. 
on  temperature  in  tubercular  menin- 
gitis of  young  infants,  116. 


Hammond  on  trephining  in  general  me- 
ningeal hemorrhage,  168. 
Hammond's  classification  of  chronic  cere- 
bral meningitis,  169. 
Haslam  on  insanity,  196. 
Headache  in  hypersemia  of  brain,  Jaccoud 
on,  45. 
treatment  of,  97. 
Heart-disease  and  insanity,  281-282. 
relationship  of,  to  embolism,  70. 
Hemiplegia  in  hyperaemia   of  brain,  De- 
chambre  on,  47. 
Grisolle  on,  47. 
Hemorrhage,  extra-dural,  Erichsen's  views 
on,  167. 
relationship  of,  to  evolution  of  neo- 
membranes,  157. 
Hemorrhagic  infarction,  23. 

cerebral,  diagnosed  from  cerebral 
embolism,  79. 
pachymeningitis,  162. 
pseudo-membranous  phlegmasia,  162. 
Hemorrhoidal  discharge,  sudden  arrest  of, 

as  cause  of  cerebral  hyperaemia,  35, 
"  Herdsymptome,"  Griesinger  on,  55. 
Heynsius  on  sleep,  27. 
Horsley  on  optic  neuritis,  182-183. 

on  surgery  of  the  central  nervous  sys- 
tem, 148. 
Hughes  on  "  simulation  of  insanity  by  the 

insane,"  328. 
Hydrocephaloid  of  Marshall  Hall,  88. 
Hyperaemia,  active,  33. 
arterial,  33. 

cerebral,  anatomical  appearances  in, 
40. 
apoplectic  form,  symptoms  of,  47. 
as  caused  by  alcohol,  37. 

by  atrophy  of  the  brain,  37. 

by  cold,  35. 

by  emotion,  34. 

by  fever,  34. 

by  insolation,  35. 

by  malaria,  34. 

by  narcotic  poisons,  37. 

by  pressure  of  tumors  upon 

the  aorta,  34. 
by  reflex   gastric   irritation, 
36. 
as  causing  "  neural  irritability," 

36. 
coma  in,  49. 


346 


INDEX. 


Hyperaemia,  cerebral,  diagnosis  of,  48. 
duration  of  symptoms  of,  49. 
examination    of    abdomen    and 

thorax  in,  50. 
in    children,    symptoms   of,    re- 
sembling meningitis,  48. 
pallor  in,  49. 
partial,  55. 
prognosis  of,  53. 
respiration  in,  49. 
Spitzka's    table    of    differential 

diagnosis,  50. 
symptoms  of,  43. 

general  and  diffused,  49. 
temperature  in,  49. 
treatment  of,  53. 
collateral,  62. 
congestive,  33. 
definition  of,  33. 
passive,  33. 
venous,  33. 
Hypertrophy  of  left  ventricle  as  cause  of 

cerebral  hypersemia,  34. 
Hysteria  in  organic  diseases  of  nervous 

system,  182, 
Hysterical  insanity,  274-275. 
Folsom  on,  275. 


Idiocy,  269. 

Idiopathic  meningitis,  100. 

Imbecility,  269. 

Hazard  on,  273. 
moral,  272. 
Importance  of  an  analysis  of  the  feelings 

in  the  study  of  insanity,  224. 
Impulsive  insanity,  228. 

diagnosis  of,  229. 
Incompressibility  of  cerebral  substance,  16. 
Increased  cardiac  action  as  cause  of  cere- 
bral congestion,  33. 
Independent  cardiac  hypertrophy  as  cause 

of  congestion,  33. 
Infarctions,  anaemic,  72. 
embolic,  72. 
hemorrhagic,  73. 
white,  72. 
Infectious  embolus,  62. 
Inflammation  and  thrombosis  of  the  cere- 
bral sinuses,  143. 
Influence  of  cerebral  circulation  on  sleep, 
25. 


Influence  of  inferior  thyroids  on  cerebral 
circulation,  IS. 
of  thyroid  gland  on   cerebrar  circu- 
lation, 18. 
Influenza  and  insanity,  280. 
Inhibition,  M.  Allen  Starr  on,  256. 
Injuries  to  the  head,  Forbes  Winslow  on, 
209. 
Griesinger  on,  298. 
Insane  neuroses,  201. 
Insanity,  184. 

acute  and  chronic  stage,  limit  of,  189. 
alcoholic,  277. 

chronic,  278. 
alternations    of,    Schroeder   van    der 

Kolk  on,  185. 
assumed,  327. 
brain  surgery  in,  338. 

Lanphear  on,  338. 
Bright's  disease  and,  279. 
Brush  on,  279. 

cases  involving  the  question  of  respon- 
sibility for  crime,  Folsom  on,  191. 
countenance  in,  213. 
definition  of,  186. 

Maudsley's,  188. 
diagnosis  of,  in  general,  325. 
duty  of  physician  in  cases  of,  194. 
etiology  of,  203-204. 
following  influenza,  280. 
forensic  meaning  of,  195. 
heart-disease  complicating,  281-282. 

Spitzka  on,  282. 
hysterical,  274-275. 
impulsive  epileptic,  291. 
Kraflft-Ebing  on,  197. 
legal  conception  of,  Folsom  on,  192. 
medical  meaning  of,  Folsom  on,  195. 
moral,  266. 
pathology  and  anatomical  appearance 

of,  330. 
phthisis  and,  185. 

popular  conception  of,  Folsom  on,  191. 
predisposition  to,  185-195. 
prevention  of,  195. 
prognosis  of,  329. 
recapitulation  of,  337. 
Sheppard  on,  188. 
simulation  of,  by  the  insane,  328. 
strictly  a  medical  study,  193. 
strong  but  not  conclusive  evidence  of 
innocence,  Lord  Bramwell,  197. 


INDEX. 


347 


rnsanity,  temperament  of,  Sheppard  on, 

2or. 

transitory,  276. 

Insolation  as  cause  of  cerebral  hypersemia, 
35. 

Intellectual  insanity,  223. 

Intervallary   epileptic    insanity,   Spitzka 
on,  302. 

Intra-arachnoidean  apoplexy,  163. 
hemorrhage,  Cruveilhier  on,  158. 

Introspection  in  insanity,  248. 

Irregular   or  abortive  paroxysms  of  epi- 
lepsy, Hammond  on,  292. 

Irresponsibility  of  epileptics,  Ray  on,  297. 

Isolated  facts  in  plea  of  insanity,  238. 


Jaccoud  on  general  cerebral  anaemia,  87. 

Jackson,  Hughlings,  on  psychical  states, 
290. 

Jenner,  Sir  William,  observations  on  head- 
ache and  delirium,  181. 

K. 

Katatonia,  273. 

Folsom  on,  274. 

Kahlbaum  on,  273. 

Kiernan  on,  273. 

Spitzka  on,  273, 
Kellie  on  cerebral  circulation,  21. 
Krafft-Ebing  on  acute  delirious  mania,  254. 

on  insanity,  197. 

on  transitory  insanity,  276. 


Langrau  on  meningitis,  106. 

"La  nonna,"  281. 

Lanphear  on  brain  surgery  in  insanity, 

338. 
Larvated  epilepsy,  Auzouy  on,  296. 
Lebeau  on  cerebral  circulation,  14. 
Left   middle    cerebral    artery   more    fre- 
quently plugged  than  the  right,  61. 
Legal  insanity  or  irresponsibility,  Folsom 

on,  194. 
Leptomeningitis,  99,  100. 

anatomical  appearances  of,  107. 

diagnosis  of,  104,  105. 

optic  neuritis  in,  103, 

symptoms  of,  101. 

temperature  in,  101, 

treatment  of,  108. 


Lesions  from  ear-disease,   Landon  Carter 
Gray  on,  147. 

G.  Newton  Pitt  on,  146. 
Linear  craniotomy,  270. 

Gueniot  on,  270. 

Packard  on,  270. 

Tuholske  on,  271. 

two  cases  of,  271. 
Liver  capillaries,  size  of,  73. 
Lord  Blackburn   on   the  jury's    duty  in 

cases  of  insanity,  197. 
Lung  capillaries,  size  of,  73. 
Lymphatics,  meningeal,  12. 

perivascular,  12. 
Lypemania,  241. 

M, 

Macewen  on  aural  surgery,  145. 

Malaria  as  cause  of  cerebral  hyperaemia, 

34. 
Mania,  Brush  on,  255. 

characteristics  of,  255, 
Clouston  on,  252,  255. 
course  of,  258. 
delirious,  acute,  251. 
Jessen  on,  252. 
morbid  anatomy  of,  Spitzka  on, 

253. 
treatment  of,  253. 
gravis,  255. 
preceding  epileptic  fit,  Maudsley  on, 

300. 
prognosis  of,  260. 
treatment  of,  259. 
Van  der  Kolk  on,  258, 
Manie  de  grandeur,  312. 
Marasmic   thrombosis   as   source   of  em- 
bolus, 73. 
Marshall  Hall  on  hydrocephaloid  disease, 

88. 
Masked  epilepsy,  Maudsley  on,  297. 
Mastoid  process,  caries  of,  Niemeyer  on, 

144. 
Maudsley's  classification  of  insanity,  200, 

201. 
Mechanism  of  production  of  symptoms  of 

brain-disease,  173. 
Medical  experts,  duties  of,  194, 
Medico-legal  aspects  of  emotional  insanity, 

231. 
Melancholia,  240, 
affective,  242. 


348 


INDEX. 


Melancholia  attonita,  245. 
hypochondriacal,  242. 
moral  treatment  of,  247. 
euieide  in,  244. 
treatment  of,  249. 
Mendel   on   morbid   anatomy  of  general 

paralysis,  319. 
Meningeal  blood-tumors,  148. 

hemorrhage,  anatomical  appearances 
of,  166. 
causes  of,  166, 

Gowers  on,  165. 
coma  in,  Niemeyer  on,  166. 
convulsions  in,  Gowers  on,  167. 
Durand-Fardel  on,  167. 
extra-dural,  165. 
general,  165. 

Gowers  on,  165. 
haemophilia    and    gout    as 

causes  of,  167. 
Hammond  on,  167. 
miliary  aneurisms  in,  167. 
periarteritis  in,  167. 
prognosis  of,  167. 
treatment  of,  168. 
trephining  in,  Hammond  on, 
168. 
more     common    in     adult     life, 

167. 
of  traumatic  origin,  167. 
Prus  on,  167. 
sub-arachnoid,  165. 
Bub-dural,  165. 
symptoms  of,  166. 
Valleix  on,  167. 
lymphatics,  12. 
Meninges,  miliary  tubercles  of,  Gowers  on, 

181. 
M6ningite  de  la  base,  111. 
Meningitis,  chronic  basilar,  174. 

anatomical    appearances   of, 

177-178. 
diagnosis  of,  179. 
etiology  of,  174,  175. 
prognosis  of,  178. 
symptoms  of,  175,  176. 
treatment  of,  179. 
chronic  cerebral,  169. 

generalities,  180, 
Hammond   on   classification 
of,  169. 
in  general,  Gowers  on,  181. 


Meningitis,  chronic  vertical,  anatomical 
appearances  of,  169. 
diagnosis  of,  174. 
duration  of,  171. 
etiology  of,  169. 
intermittence   of   symptoms 

in.  Fox  on,  171. 
prognosis  of,  174. 
symptoms  of,  170. 
treatment  of,  174. 
distinction  of,  from  hysteria,  182. 

from  otitis,  182. 
septic,    treatment     of,    Gowers    on, 

179. 
syphilitic,  chronic,  Gowers  on,  180. 
Menstrual  discharge,  sudden  arrest  of,  as 

cause  of  cerebral  hypersemia,  35. 
Mental  disturbances  in  Basedow's  disease, 
Emminghaus  on,  282. 
Van  der  Kolk  on,  282. 
overstrain  as  cause  of  cerebral  hyper- 
emia, Nothnagel  on,  32. 
Spitzka  on,  32. 
Mesenteric  veins,  clots  in,  73. 
Meynert  on  clinical  types  of  general  par- 
alysis, 304. 
on  vaso-motor   disorder  as  cause  of 
general  paralysis,  311, 
Momentary  congestions  of  brain,  31. 
Monomania,  260. 
Montesquieu  on  insanity,  196. 
Moral  causes  of  insanity,  209. 
imbecility,  272, 
insanity,  266, 

diagnosis  of,  268. 
Polsom  on,  267. 
Pinel  on,  267. 
Pritchard  on,  267. 
Tuke  on,  268. 
Westphal  on,  267. 
Motive,  Dr.  Taylor  on,  233. 

question  of,  in  insanity,  233. 
Murchison  on  distinction  between  uraemia 

and  cerebro-spinal  meningitis,  132. 
Muscular  coat  of  vessels  of  brain,  31 
Mutability  of  symptoms  in  brain-disease, 
69. 

N. 

Narcotic  poisons  as  causing  cerebral  hy- 

persemia,  37. 
Neo-membranes  of  the  dura  mater,  153. 


INDEX. 


349 


Neo-membranes  of  the  dura  mater,  Bail- 
larger  on,  157. 
Bayle  on,  156. 
Brunet  on,  154. 
Calmeil  on,  155. 
capsular  form  of,  161. 
Charcot  on,  153. 
frequently  developed  as  the 
result     of     inflammatory 
processes,      Charcot      on, 
156,  157. 
Guido-Weber  on,  156. 
Hasse  on,  155. 
Heschel  on,  154. 
Kolliker  on,  155. 
Schuberg  on,  155. 
structure  of,  160. 
vessels  of,  160. 
Virchow  on,  154. 
"  Neural  irritability"  as  result  of  cerebral 

hyperaemia,  36. 
Neuralgia  in  children,  113,  114. 
Niemeyer  on  caries  of  the  mastoid  process, 
144. 
on  encapsulated   blood-sacs  of  dura 

mater,  149. 
on  general  cerebral  anemia,  90. 
on  hsematoma  of  dura  mater,  151. 
on  nosology  of  cerebral   hypersemia, 
31. 
Night  vigils  as  cause  of  cerebral  hyper- 
semia, 35. 
Nitro-glycerin  in  general  cerebral  anaemia, 

98. 
Nose,  red  or  blue,  significance  of,  22. 
Nosology  of  cerebral  hyperaemia,  29. 
Nothnagel  on  mental  overstrain  as  cause 

of  cerebral  hyperfemia,  32. 
Nutritive    plasma,   condition    of,    during 
sleep,  27. 

O. 

Ophthalmic    arteries,  influence  of,   upon 

cerebral  circulation,  22. 
Optic  nerves  in  drunkards,  Allbutt  on,  171. 

neuritis,  Horsley  on,  182,  183. 
Othaematomata,  159. 
Otorrhoea,  141. 
Over-indulgence  in  the  pleasures  of  the 

table  as  cause  of  cerebral  hyperaemia,  35. 
Oxidation,  effects  of,  in  the  production  of 

sleep,  28. 


P. 

Pacchionian  bodies  in  cerebral  congestion, 

43. 
Pachymeningitis,  138. 

anatomical  appearances  of,  145. 

Niemeyer  on,  145. 
duration  of,  147. 
etiology  of,  139,  140. 
external,  Gowers  on,  138. 
prognosis  of,  148. 
Schroeder  van  der  Kolk  on,  138- 

139. 
significance  of  acute,  147. 
sudden  death  in,  141-142. 
symptoms  of,  147. 
treatment  of,  148. 
trephining  in,  Gowers  on,  148. 
hemorrhagic,  162. 
internal,  148. 

mild    form,   non-recognition  of, 

164. 
Niemeyer  on,  149. 
Pantophobia,  241. 
Paracentral  lobule,  condition  of,  in  some 

cases  of  tubercular  meningitis,  118. 
Paralytic    dementia,    early   diagnosis   of, 

Seguin  on,  316. 
Paranoia,  260-262. 
Spitzka  on,  262, 
Starr,  M.  Allen,  on,  262. 
Partial  cerebral  anaemia,  57. 
treatment  of,  86. 
hyperaemia,  55. 
Passive  cerebral  congestion,  Gowers  on,  41. 
cerebral  hyperaemia  as  caused  by  al- 
tered   or  pathological    condi- 
tions of  the  lungs,  38. 
as  caused  by  impediments  to  func- 
tions of  the  heart,  38. 
as  caused  by  pressure  on  venous 

trunks,  38. 
as  caused  by  strangulation,  38. 
as  caused  by  thoracic  aneurism, 

38. 
as  caused  by  tumors  pressing  on 

jugular  veins,  38. 
as  caused  by  violent  expiratory 
efforts,  38. 
Pathological  anatomy  of  cerebral  anaemia, 

63. 
Peripheral  arteries  in  thrombosis,  68. 


350 


INDEX. 


Perivascular  canals,  12. 
lymphatics,  12. 
sheath,  12. 
spaces,  12. 
"  Petit  mal"  and  "  grand  mal  intellectuel" 

of  Falret,  Samt  on,  301. 
Philosophy  of  the  cerebral  circulation,  13. 
Phlegmasia  alba  dolens  as  source  of  em- 
bolus, 73. 
Physical  causes  of  insanity,  207. 

effects  upon  temperaments,  influence 
of,  Wigan  on,  202. 
Pia-arachnoid  membrane,  its  peculiarities, 

180. 
Pia  mater,  capillaries  of,  24. 

relation    of,  to   cerebral    convo- 
lutions, 24. 
Pinel  on  moral  insanity,  267. 
Pinel's  classification  of  insanity,  199. 
Pitt,  G.  Newton,  on  ear-disease,  146. 
Plea  of  insanity,  Bucknill  on,  236. 
Forbes  Winslow  on,  235. 
Haslam  on,  235. 
Lord  Blackburn  on,  236. 
Lord  Bramwell  on,  236. 
Lord  Chief-Justice  Coke  on,  234. 
Lord  Chief-Justice  Mansfield  on, 

234. 
Lord  Erskine  on,  234. 
Lord  Hale  on,  234. 
Sir  James  Stephen  on,  236. 
Poltz  on  cerebro-spinal  liquid,  24. 
Position  as  cause  of  cerebral  hypersemia,  35. 
Post-cervical  pains  in  melancholia,  Lan- 

don  Carter  Gray  on,  250. 
Posterior  cranial  fossa,  symptoms  of  en- 
croachment upon,  85. 
Predisposing  causes  of  insanity,  204. 
Pre-epileptic  insanity,  Spitzka  on,  301. 
Premeditation  in  epilepsy,  Eeheverria  on, 

297. 
Pressure,  circumscribed,  on  brain,  63. 
in  cranial  space,  causes  of,  62. 
limited,  on  brain,  62. 
partial,  on  brain,  62. 
Pritchard  on  moral  insanity,  267. 

on  plea  of  emotional  insanity,  238. 
Protopathie  insanity  of  Bucknill  and  Tuke, 

262. 
Prus  on  general  meningeal  hemorrhage, 

167. 
Pulmonary  abscesses,  73. 


Pulsation   of  the  smaller  vessels   of  the 

brain,  23. 
Puncta  vasculosa  in  cerebral  hypersemia, 

40. 
Pyasmic  abscesses,  73. 

R. 

Ranney's  table  of  differential  diagnosis  in 
pachymeningitis,  151-152. 

Ray  on  epilepsy  and  its  legal  consequences, 
293. 
on  irresponsibility  of  epileptics,  297. 
on  wills  and  contracts  in  alleged  in- 
sanity, 192. 

Recognition  of  right  from  wrong  by  the 
insane,  234-236. 

Regurgitation,  venous,  73. 

Repression    of    menstruation    in    melan- 
cholia, Gehring  on,  250. 

Responsibility,  Bucknill  on,  295. 

"  Rete  mirabile,"  23. 

Retinal  congestion  as  connected  with  cere- 
bral hypersemia,  43. 

Rheumatism,  relationship  of,  to  embolism, 
69. 

Rogers's  pathognomonic  symptom  of  tuber- 
cular meningitis,  116. 

Rokitansky  on  morbid  anatomy  of  general 
paralysis,  319. 


Samt  on  "petit  mal"  and  "  grand  mal  in- 
tellectuel" of  Falret,  301. 

Sankey  on  impulsive  insanity,  229. 

Savage  on  dementia,  265. 
on  insanity,  196. 

Scars  upon  the  scalp,  299. 

Schenck  on  impulsive  insanity,  231. 

Schopenhauer  on  the  normal  man,  220. 

Schroeder  van   der  Kolk  on  the  cerebral 
circulation,  IS. 
on  the  production  of  sleep  from  di- 
minished change  of  matter,  28. 

Schiile  on  insanity,  197. 

Seguin  on  hysteria  complicating  organic 
diseases  of  the  nervous  system,  182. 

Senn,  surgery  of  the  brain,  145,  183. 

Sero-sanguinolent  cysts,  162. 

Serous   transudation   in    cerebral    hyper- 
semia, 41. 

Sheath,  perivascular,  12. 


INDEX. 


351 


Simon  on  thyroids  of  birds,  19. 
Sinuses  of  dura  mater,  24. 
Skin-eruptions    in     brain-disease,    Ham- 
mond on,  141. 
Sleep  as  influenced  by  contraction  of  ves- 
sels, 28. 
by  oxidation,  28. 
influence  of,  on  cerebral  activity,  27. 
on  circulation,  28. 
Space,  subarachnoid,  11. 
Spaces,  perivascular,  12. 
Specific  infectious  emboli,  73. 
Spitzka  on  insanity,  196. 

on    mental    overstrain    as    cause   of 

passive  hyperaemia,  32. 

on  nosology  of  cerebral   hyperaemia, 

31. 

Spitzka's  table  of  the  differential  diagnosis 

of  cerebral  hyperaemia  and  anaemia,  50. 

Standards  by  which  insanity  is  measured, 

220. 
Starr,  M.  Allen,  on  inhibition,  256. 
on  melancholia,  240. 
on  paranoia,  262. 
Stomachic  vertigo  as   distinguished  from 

cerebral  hyperaemia,  49. 
Strabismus  in  hysteria,  Gowers  on,  182. 
Strangulation  as  cause  of  passive  hyper- 
emia, 38. 
Suicide  in  melancholia,  244. 
Symptomatology  of  anaemia  from  collateral 

oedema,  82. 
Symptoms  of  cerebral  hyperaemia,  43. 
of  depression  in  cerebral  hyperaemia, 

43. 
of  irritation  in  cerebral   hyperaemia, 
43. 
philosophy  of,  43. 

T. 

Table   of    differential    diagnosis   between 
cerebral    thrombosis     and 
embolism,  80. 
in  meningitis,  135,  136 
in  pachymeningitis,  by  Ran- 
ney,  151. 
Tardier  on  peri-uterine  hsematoceles,  162. 
Tentorium  cerebelli,  function  of,  63. 
Terminal  arteries,  Cohnheim  on,  72,  74. 
cerebral  arteries,  Charcot  on,  74. 
Buret  on,  74. 
Heubner  on,  74. 


Terminal  dementia,  264. 
Thought,  M.  Allen  Starr  on,  289. 
Thrombosis,  58,  68. 

as  cause  of  embolism,  59. 
differentiated  from  embolism,  80. 
of  femoral  vein  as  source  of  embolus, 
73. 
Thyroid  gland,  influence  of,  on  cerebral 

circulation,  18. 
Todd  on  lead-poisoning,  320. 
Training  and  surroundings  of  the  insane, 

Folsom  on,  195. 
Transitory  insanity,  Folsom  on,  277. 

Krafft-Ebing  on,  276. 
Transmutation  of  nervous  diseases,  Trous- 
seau on,  208. 
Treatment,  early,  of  insanity,  247. 
in  melancholia,  249. 
of  general  cerebral  anaemia,  93. 
Trousseau  on  nosology  of  cerebral  hyper- 
aemia, 31. 
Tubercular  meningitis,  110. 

anatomical   appearances  of,  119, 
120. 
Gowers  on,  119,  120. 
Bokai  on,  119. 
condition   of  paracentral    lobule 

in,  121. 
diagnosis  of,  122. 
embarrassment  of  respiration  in, 

114, 
Gowers  on,  117,  118. 
Grisolle  on,  120. 
Hammond  on,  120. 
Jean  Charcot  on,  121. 
Koch's  lymph  in,  121. 
miliary  deposits  in,  Ranney  on, 

121. 
moral  change  in,  112. 
mutability  of  symptoms  in,  116. 
period  of  invasion  in,  112. 

of  life   at   which    it  occurs, 
110. 
prognosis  of,  123. 
Souques  on,  121. 
special  symptoms  of,  117,  118. 
stages  of,  114. 
treatment  of,  123. 
ventricular  surgery   n,  123. 
Tuczek   on   morbid   anatomy   of    general 

paralysis,  319. 
Tuholske  on  linear  craniotomy,  270. 


352 


INDEX. 


Tuke  on  moral  insanity,  268. 
Typhomania,  251,  262. 

U. 

Ulcerations  as  source  of  emboli,  73. 
Unconscious  cerebration,  187. 

V. 

Valleix  on  general  meningeal  hemorrhage, 

167. 
Van  der  Kolk  on  "  epileptic  vertigo,"  300. 
on  mental  disturbances  in  Basedow's 
disease,  282. 
Van  der  Kolk's  classification  of  insanity, 

199. 
Variation  in  quantity  of  blood  in  cranium, 
16. 
in  volume  of  cerebral  circulation,  17. 
Vascular  action  of  brain  during  sleep,  26. 
when  awake,  26. 
tension  of  cerebral  circulation,  17. 
Vascularity  of  child's  brain  as  compared 

with  adult's,  42. 
Vaso-motor  origin   of   general  paralysis, 

Meynert  on,  311. 
Venous  regurgitation,  73. 
"Ventricular  meningitis,"  111. 
Vertebrals,  influence  of,  on  cerebral  circu- 
lation, 20. 
Vertigo  peculiar  to  encroachment  on  pos- 
terior cranial  fossa,  85,  86. 
Vessels  of  brain,  firmness  of,  23. 

of  face,  influence  of,  on  cerebral  cir- 
culation, 19.  ' 
Virchow  on  capillary  emboli,  69. 


Virchow  on  diffusive  currents,  12. 

on   hsematoma    of   the    dura   mater, 
148. 
Volitional  centres  affected  in  all  forms  of 

insanity,  237. 
Vulpian  on  cerebral  softening,  81. 

W. 

Want  of  harmony  of  the  individual  with 

his  surroundings,  219. 
Watson  on  the  different  modes  of  dying, 

104. 
Weir  Mitchell's  rest-cure,  276. 
Wernicke  on  morbid  anatomy  of  general 

paralysis,  319. 
Westphal  on  moral  insanity,  267. 
Wet  pack,  Blandford  and  Sheppard    on, 

253. 
Whytt  on  tubercular  meningitis.  111. 
Will-power,  annihilation  of,  an  essential 

feature  of  all  insane  acts,  229. 
Wills   and   contracts   in  alleged  cases  of 
insanity,  Folsom  on,  192. 
Ray  on,  192. 
Winslow  on  injuries  to  the  head,  297. 

on  prima  facie  evidence  of  insanity, 

238. 
"Plea  of  Insanity,"  231. 
Wounds  as  sources  of  emboli,  73. 

Z. 

Ziemssen  on  high  temperature  in  cerebro- 
spinal meningitis,  132. 
on  micro-organisms  in  epidemic  men- 
ingitis, 133. 


THE   END 


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